Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure expired medications were not available
for use for one resident (Resident 99) and in an E-Kit (a kit containing urgently needed medications to
quickly treat the residents without delay)
This failure resulted in Resident 99 receiving an expired medication. This failure also had the potential for
facility residents to receive sub-therapeutic medication therapy from expired medications.
Findings:
1. On February 26, 2025, at 8:35 a.m., during a medication pass observation, LVN 1 prepared morning
medications doses which included Atrovent (medication for shortness of breath) inhaler for Resident 99.
The expiration date on the manufacturer's label on the canister of the Atrovent inhaler indicated, 12/2024,
It was observed LVN 1 did not check the expiration date of Atrovent inhaler during the morning medication
preparation for Resident 99.
In a concurrent interview, LVN 1 confirmed the expiration date. LVN 1 stated the medication was brought in
with Resident 99 to the facility and a new Atrovent inhaler needed to be ordered from the pharmacy.
On February 26, 2025, Resident 99's record was reviewed:
The resident was admitted to the facility on [DATE];
A review of the physician order on February 10, 2025, for ipratropium (generic name for Atrovent) HFA (a
type of inhaler propellant) aerosol solution 17 microgram per actuation (mcg/act) to be given to Resident 99
two puffs orally four times a day for COPD (chronic obstructive pulmonary disease, a lung disease resulting
in breathing difficulties); and
A review of the medication administration record (MAR) for Resident 99 indicated Atrovent inhaler was
administered to Resident 99 four times a day since February 11, 2025.
2. On February 25, 2025, at 11:25 a.m., during an inspection of Medication Cart #2 with LVN 2, there was a
CIII-CV (referring to Schedule III to V controlled substances) E-Kit with an expiration
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 15
Event ID:
555383
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
date, 12/2024.
Level of Harm - Minimal harm
or potential for actual harm
Inside the same CIII-CV E-Kit, there were four tablets of carisoprodol (generic name for Soma, a muscle
relaxant) 350 mg (milligram, unit of measurement) with an expiration date, 12/30/24.
Residents Affected - Some
In a concurrent interview, LVN 2 confirmed carisoprodol tablets were expired.
A review of the facility's policy and procedure titled, Expired Medications, last revised, April 2019, indicated,
.Expired medications are identified and removed from current medication supply in a timely manner for
disposition .
A review of the The facility's policy and procedure titled, Emergency Medications, last revised, April 2007,
indicated, .The Consultant Pharmacist shall inspect the emergency medications kits monthly and record
the findings on the record maintained with each kit .
A review of the facility's policy and procedure titled, Administering Medications, last revised, April 2019,
indicated, .Medications are administered in a safe and timely manner, and as prescribed .The
expiration/beyond use date on the medication label is checked prior to administering .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 2 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure, for three residents (Resident 3, 18, and 32), the
consultant pharmacist identified, and made recommendations on, non-standardized and inconsistent
procedures by nursing staff for holding blood pressure medications that were ordered by the physician
without holding parameters to residents.
This failure had the potential for ineffective management of the residents' hypertension (high blood pressure
(BP).
Findings:
On February 27, 2025, during a record review for Resident 3, 18, and 32, the following was noted:
1. Resident 3 was admitted on [DATE], with diagnoses which included, hypertensive heart disease with
heart failure;
A review of the physician order on January 30, 2025, for lisinopril (BP) medication 40 mg (milligram, unit of
measurement) with the direction to give one tablet by mouth one time a day for hypertension with no hold
parameters;
A review of the physician order on January 30, 2025, for carvedilol (BP) medication 3.125 mg with the
direction to give one tablet by mouth two times a day for hypertension with no hold parameters;
A review of the medication administration record (MAR) for Resident 3 indicated lisinopril and carvedilol
morning doses were administered when:
a. On February 4, 2025, based on BP measurement of 100/57,
b. On February 7, 2025, based on BP measurement of 97/69,
c. On February 8, 2025, based on BP measurement of 100/60, and
d. On February 19, 2025, based on BP measurement of 102/80.
A review of the care plan for cardiopulmonary related to diagnosis of hypertension, hyperlipidemia (high
blood fat level), and stroke indicated, The resident will have systolic pressure between 160 and 90, and
diastolic pressure between 100 and 40 .
2. A review of the medical record indicated Resident 18 was admitted on [DATE], with diagnoses which
included, hypertension (high blood pressure);
A review of the the physician order on March 7, 2024, for Lotensin (blood pressure medication) 10 mg with
the direction to give one tablet by mouth one time a day for hypertension;
A review of the MAR for Resident 18 indicated Lotensin morning doses were held when:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 3 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
a. On October 8, 2024, was held, based on BP measurement of 109/57,
Level of Harm - Minimal harm
or potential for actual harm
b. On October 22, 2024, based on BP measurement of 117/56, and
c. On October 24, 2024, based on BP measurement of 113/48.
Residents Affected - Few
3. A review of the medical record indiated Resident 32 was admitted on [DATE], with diagnoses which
included, hypertension;
A review of the physician order on February 15, 2025, for lisinopril 20 mg with the direction to give one
tablet by mouth one time a day for hypertension with no hold parameters;
A review of the physician order on February 14, 2025, for carvedilol 3.125 mg with the direction to give one
tablet by mouth two times a day for hypertension with no hold parameters;
A review of the MAR for Resident 32 indicated lisinopril and carvedilol morning doses were held when:
a. On February 16, 2025 based on BP measurement of 102/57,
b. On February 17, 2025 based on BP measurement of 103/61;
However, the doses were given to Resident 32 on February 27, 2025, based on BP measurement of
104/61.
A review of the care plan for cardiopulmonary related to diagnosis of hypertension, hyperlipidemia (high
blood fat level), and stroke indicated, The resident will have systolic pressure between 160 and 90, and
diastolic pressure between 100 and 40 .
On February 26, 2025, at 11:30 a.m., an interview was conducted with Licesned Vocational Nurse (LVN 1),
when asked the reason for holding the BP medication with no hold parameters for Resident 34 based on
BP measurement of 104/61, LVN 1 stated she would use nursing clinical judgment to decide when to hold
and not administer blood pressure (BP) medications. LVN 1 stated she would hold the blood pressure
medication dose if the BP measurement was below 120/70 (millimeter of Mercury, mmHg, unit of pressure)
and hold beta blockers (one class of BP medication) if the heart rate measurement is below 60.
On February 27, 2025, at 11 a.m., an interview was conducted with LVN 2, she stated the BP medications
were given to residents based on nurse's clinical judgment. LVN 2 stated she would like to have hold
parameters for BP medications. LVN 2 stated the facility had always used the nursing judgment to give or
not to give BP medications based on the BP measurement.
On February 27, 2025, at 4:35 p.m., an interview was conducted withthe Director of Nursing (DON ), stated
the expectation was for nursing staff to use nursing clinical judgment to determine whether blood pressure
medications should be held and not be given the to residents. The DON stated physicians should be
contacted only if the BP medications were held for three days or more.
The DON was not able to provide policies and procedures on holding BP medications based on vital signs.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 4 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On February 28, 2025, at 9:30 a.m., an interview was conducted with the Consultant Pharmacist (CP),
stated the he did not identify and made recommendations on the inconsistencies on nursing staff making
independent decisions to hold BP medications with no holding parameters ordered by a physician.
According to California Code of Regulation (CCR) Title 16, Section 2518.5, Scope of Vocational Nursing
Practice:
.The licensed vocational nurse performs services requiring technical and manual skills which include the
following:
(a) Uses and practices basic assessment (data collection), participates in planning, executes interventions
in accordance with the care plan or treatment plan, and contributes to evaluation of individualized
interventions related to the care plan or treatment plan.
(b) Provides direct patient/client care by which the licensee:
(1) Performs basic nursing services as defined in subdivision (a);
(2) Administers medications;
(3) Applies communication skills for the purpose of patient/client care and education; and
(4) Contributes to the development and implementation of a teaching plan related to self-care for the
patient/client .
The facility's policy and procedure titled, Medication Regimen Reviews, last revised, May 2019, was
reviewed, and it indicated:
.The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility
receiving medications .The MRR involves a thorough review of the resident's medical record to prevent,
identify, report and resolve medication related problems, medication errors and other irregularities .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 5 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure antipsychotic medications (medication to treat
thought disorder that changes sense of reality) were used after non-pharmacological interventions were
tried and the residents were assessed to be distressed and a danger to self or others.
This failure resulted in one resident (Resident 18) with dementia receiving an unnecessary antipsychotic
medication with a boxed warning issued by the Food and Drug Administration (FDA, a federal agency that
regulates drugs and other products).
A boxed warning is the strongest warning the FDA requires and signifies the drug carries a significant risk
of serious events.
Findings:
A review of Resident 18's medical record was conducted:
Resident 18 was admitted on [DATE], with diagnoses which included, unspecified dementia with psychotic
disturbance;
A review of the physician order on March 6, 2024, for Seroquel 50 mg (milligram, unit of measurement) with
the direction to give one tablet by mouth two times a day for psychosis manifested by hallucinations;
A review of the hospital record prior to admission to the facility indicated Resident 18 did not have a history
of psychosis and Resident 18's past medication history did not include an antipsychotic medication;
A reveiw of the hospital record indicated, while a patient at the hospital, Resident 18 received one dose of
Seroquel 50 mg, a one-time order, on March 5, 2024, at 10:26 p.m. for agitation and one dose Seroquel 50
mg, a one-time order on March 6, 2024, at 12:25 a.m.;
A review of Resident 18's care plan indicated there was a medical diagnosis of psychosis as evidenced by
auditory/visual hallucinations dated, March 6, 2024;
A review of Resident 18's Minimum Data Set (MDS, a federally mandated process for clinical assessment
of all residents in Medicare and Medicaid certified nursing homes) dated, March 13, 2024, indicated
Resident 18 did not have hallucinations (perceptual experiences in the absence of real external sensory
stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality), and Resident 18's
Brief Interview for Mental Status (BIMS, a screening tool that can help identify cognitive impairment in older
adult) score was 9 (moderately impaired); and
The facility's medical record did not contain evidence non-pharmacological interventions were tried and
Resident 18's thoughts, moods, and mental status placed the resident in significant distress and a danger
to self or others.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 6 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On February 27, 2025, at 12:05 p.m., during an interview, the Director of Nursing (DON), stated because
Resident 18 received one-time doses of Seroquel 50 mg at the hospital the facility did not attempt
non-pharmacological intervention and assess the resident for danger to self or others. The DON also stated
there was no psychiatric consult done for the resident.
A review of the facility's policy and procedure titled, Psychotropic Drug Treatment, last revised, December
2020, indicated,
.The resident has the right to be free from unnecessary drugs/medications and protection from medication
errors. When their use is indicated, the facility should use the least restrictive alternative for the least
amount of time and document on-going evaluation of the need for psychotropic drug treatment
.Psychotropic drugs shall be used only after alternative methods have been tried unsuccessfully and only
upon the written order of a physician and after informed consent has been obtained by the physician from
the resident or his/her representative .
A review of the boxed warning for Seroquel by the FDA: Warning: Increased mortality in elderly patients
with dementia-related psychosis .Elderly patients with dementia-related psychosis treated with
antipsychotic drugs are at an increased risk of death .Seroquel is not approved for the treatment of patients
with dementia-related psychosis .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 7 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility had a medication error rate of 11.11% when three
medication errors occurred out of 27 opportunities during the medication administration for two out of seven
residents (Resident 99 and 39).
Residents Affected - Few
The deficient practice resulted in medications not given in accordance with the prescriber's orders and had
the potential for residents not receiving the full therapeutic effects of medications with the potential for
worsening of residents' medical conditions.
Findings:
1. On February 26, 2024, at 8:35 a.m., during a medication pass observation, Licensed Vocational Nurse
(LVN 1) was observed preparing five medications to Resident 99. LVN 1 was observed handing the
fluticasone/salmeterol (generic for Advair 250/50, used for chronic obstructive pulmonary disease [COPD],
a lung disease causing breathing problems) inhaler to Resident 99 with an instruction, in English, to spit out
the water in the cup on the bedside tray.
Resident 99 did not positively acknowledge understanding of the instruction LVN 1 gave Resident 99.
Resident 99, then, was observed taking one puff by mouth from the Advair inhaler and swallowing the water
after rinsing the mouth. LVN 1 was observed to step away and not witnessing Resident 99 spitting out the
rinsed water.
On February 26, 2025, at 11:30 a.m., an interview was conducted with LVN , 1 stated it was out my hand
because Resident 99 swallowed the water even after instructing Resident 99 to spit out the water after
rinsing the mouth.
LVN 1 stated Resident 99's English was not the problem, but Resident 99's hearing was not good.
LVN 1 stated it would have been better if LVN 1 used a designated facility interpreter or Spanish speaking
staff at the facility.
On February 28, 2025, at 8:35 a.m., during an interview with a Spanish-speaking Certified Nursing
Assistant (CNA 1), CNA 1 stated Resident 99 preferred Spanish.
It was noted Resident 99 was not able to understand when he was spoken to in English regarding the use
of the inhaler and spitting out water after rinsing the mouth.
CNA 1 also stated Resident 99 did not have issues with hearing and was observed to communicate
effortlessly in Spanish with CNA 1.
On February 28, 2025, at 9:30 a.m., during an interview, the Consultant Pharmacist (CP) stated Resident
99 should have spit out the water after rinsing the mouth after Advair use to prevent oral fungal infection.
A review of the prescribing information for fluticasone/salmeterol DISKUS inhaler from Dailymed Website (a
national database for prescribing information submitted to the Food and Drug Administration, FDA):
.Fluticasone Propionate/Salmeterol DISKUS should be administered as 1 inhalation twice daily
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 8 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
by the orally inhaled route only. After inhalation, the patient should rinse his/her mouth with water without
swallowing to help reduce the risk of oropharyngeal candidiasis (fungal infection of the mouth) .
2. On February 26, 2025, at 8:35 a.m., during a medication pass observation, LVN 1 prepared morning
medications doses which included Atrovent (medication for shortness of breathing) inhaler for Resident 99.
The expiration date on the manufacturer label on the canister of the Atrovent inhaler indicated, 12/2024,
It was observed LVN 1 did not check the expiration date of Atrovent inhaler during the morning medication
preparation for Resident 99.
In a concurrent interview, LVN 1 confirmed the expiration date. LVN 1 stated the medication was brought in
with Resident 99 to the facility and a new Atrovent inhaler needed to be ordered from the pharmacy.
On February 26, 2025, a review of Resident 99's medical record was conducted. Resident 99 was admitted
to the facility on [DATE];
A review of the physician order on February 10, 2025, for ipratropium (generic name for Atrovent) HFA (a
type of inhaler propellant) aerosol solution 17 microgram per actuation (mcg/act) to be given to Resident 99
two puffs orally four times a day for COPD (chronic obstructive pulmonary disease, a lung disease resulting
in breathing difficulties); and
A review of the medication administration record (MAR) for Resident 99 indicated Atrovent inhaler was
administered to Resident 99 four times a day since February 11, 2025.
3. On February 26, 2025, at 8:25 a.m., during a medication pass observation, LVN 1 prepared and
administered two tablets of acetaminophen (generic for Tylenol, pain medication) 325 mg (milligram, unit of
measurement) to Resident 39.
On February 26, 2025, Resident's 39's medical record indicated there was a physician order on September
3, 2024, for Tylenol 325 mg, with the direction to give one tablet by mouth every 6 hours as needed for pain.
Resident 39's medication administration record (MAR) indicated LVN 1 had documented the administration
of one tablet of Tylenol 325 mg.
On February 26, 2025, at 11:30 a.m.,an interview was conducted with LVN 1, stated the dose should have
been one tablet of Tylenol 325 mg, but LVN 1 gave two tablets instead to Resident 39.
A review of the facility's policy and procedure titled, Administering Medications, last revised, April 2019,
indicated, .Medications are administered in a safe and timely manner, and as prescribed .The
expiration/beyond use date on the medication label is checked prior to administering .
A review of the facility's policy and procedure titled, Administering Medications, last revised, April 2019,
indicated, .Medications are administered in a safe and timely manner, and as prescribed .The
expiration/beyond use date on the medication label is checked prior to administering .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 9 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0802
Level of Harm - Minimal harm
or potential for actual harm
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition
service.
Based on interview and record review, the facility failed to ensure a dietary staff was able to accurately
verbalize the proper cool down process (proper method of cooling cooked foods to safe temperatures).
Residents Affected - Many
This failure had the potential to expose a population of 44 residents to foodborne illnesses (illnesses
resulting from eating contaminated food).
Findings:
On February 27, 2025, at 2:40 p.m., an interview was conducted with the [NAME] regarding the cool down
process. The [NAME] stated the cooling process from hot food temperature of 135 degrees Fahrenheit
(°F- unit of measurement) to ambient temperature of 70°F would take one hour and from
70°F to a cold temperature of 40°F, it would take less than an hour. The [NAME] further stated
when she had questions about the cool-down process, she would refer to the cool down log.
A review of the facility policy and procedure titled, Food Preparation and Service, dated April 2019,
indicated .Potentially hazardous foods are cooled rapidly. This is defined as cooling from 135 degrees F to
70 degrees F within 2 hours and then to a temperature of 41 F or below within the next 4 hours. The total
cooling time between 135 degrees F and 41 degrees F is not to exceed 6 hours .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 10 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to honor Resident 35's dietary preference by
serving fish during a meal.
This failure had the potential to negatively impact Resident 35, affecting the resident's nutritional status and
overall well-being
Findings:
A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE],
with diagnoses which included muscle weakness and failure to thrive (physical decline in older adults).
A review of Resident 35's MDS (Minimum Data Set an assessment tool) dated November 28, 2024,
indicated a BIMS (Brief Interview for Mental Status) score of 14 (cognitively intact).
A review of Resident 35' s meal ticket indicated .Lunch .NO: FISH .Dinner .NO: FISH .
On February 27, 2025, at 11:42 a.m., during tray line observation, Resident 35 's tray ticket was reviewed
and indicated the NO FISH preference for both lunch and dinner.
On February 27, 2025, at 12:15 p.m., the [NAME] placed a slice of fish on Resident 35's tray.
On February 27, 2025, at 12: 34 p.m., during an interview with the [NAME] and the Dietary Manager (DM),
the [NAME] stated she missed that; and the DM stated serving food against Resident 35's preferences
could upset the resident and potentially lead to reduced food intake.
A review of the facility policy and procedure titled Resident Food Preferences, dated July 2017, indicated
.Individual food preferences will be assessed upon admission and communicated to the interdisciplinary
team .the staff will .the resident is satisfied with .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 11 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food
preparation and storage practices when:
Residents Affected - Many
1. Turkey and bologna were not maintained at safe temperatures within the refrigerator;
2. One dietary staff was observed preparing milk for residents without wearing a beard net;
3. The airconditioning unit air inlet /outlet grill was dirty;
4. An unlabeled juice container, intended for cleaning the grill, was stored alongside food items; and
5. A quaternary (quat) sanitizer test kit readily available in the kitchen was expired.
These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting
contaminated food) among a vulnerable population of 44 out of 45 residents who received food prepared in
the facility's kitchen.
Findings:
1. On February 25, 2025, at 10:10 a.m., during the initial tour of the kitchen, with Dietary Manager (DM),
turkey and bologna in the reach-in refrigerator were warm to the touch. Temperature measurements
indicated:
-Turkey deli slices (20 slices): 46.7°F
-Bologna slices (8 slices): 46.9°F
The DM stated, safe storage temperatures for these meats should be below 41°F to prevent bacterial
growth. The DM stated storing deli meats above 41°F had the potential risk for foodborne illnesses
among residents.
On February 28, 2025, at 1 p.m., during an interview with the Registered Dietician (RD), she stated when
the turkey and bologna were not in the safe temperature range the kitchen staff were instructed to discard
the meat as there was a potential for the resident who consume it could get ill.
A review of the facility policy and procedure titled, Food Receiving and Storage, dated October 2017,
.Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout
the day by the food and nutrition services manager or designee and documented .Refrigerated foods must
be stored below 41 degrees F .
A review of the facility policy and procedure titled, Food Preparation and Services, dated April 2019, . The
danger zone, for food temperature is between 41degrees F and 135 degrees F .
2. On February 25, 2025, at 3:29 p.m., during an observation of Dietary Aide (DA) 1 and concurrent
interview with the DM, DA 1 was observed preparing resident's milk. DA 1 was observed preparing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 12 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
residents' milk without wearing a beard net. The DM stated the beard net should be worn to prevent cross
contamination.
A review of the facility policy and procedure titled, Food Preparation and Service, dated April 2019,
indicated .Food and Nutrition services staff wears hair restraints -hair net, hat, beard restraint .
Residents Affected - Many
3. On February 25, 2025, at 9:58 a.m., during a concurrent observation and interview with the DM inside
the kitchen, the air conditioning unit's air outlet grill, located above the food preparation table, was found to
have a black substance when wiped with the white paper towel.
The DM stated, it is the cook's responsibility to clean the air conditioning unit daily. The DM stated the grill
was dirty.
A review of the facility policy and procedure titled, Sanitization, dated October 2008, indicated, .Kitchen
.surfaces not in contact with food shall be cleaned on regular and frequently enough to prevent
accumulation of grime .
4. On February 25, 2025, at 10 a.m., during an observation and interview with the DM inside the kitchen, a
lemon juice container intended for cleaning the grill, was found near bundles of bananas and a bag of
bread.
The DM stated, cleaning agents should be labeled accordingly and stored separately from food items to
prevent potential contamination.
5. On February 27, 2025, at 2:50 p.m., during an observation and interview with DA 2, DA 2 used a
quaternary sanitizer test kit that had expired in September 2024 to test the sanitizing solution's
concentration.
DA 2 stated, using an expired test kit could result in inaccurate readings, leading to ineffective sanitization,
potential foodborne illness and compromised cleanliness of kitchen surfaces and utensils.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 13 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure that the required Personal
Protective Equipment (PPE) usage was clearly indicated before entering rooms of residents on Enhanced
Barrier Precautions [EBP - a set of infection control measures using gowns and gloves to reduce the
spread of multidrug-resistant organisms (MDRO)].
Residents Affected - Few
This failure had the potential to result in staff and visitors being unaware of necessary PPE requirements
prior to entering rooms requiring isolation precautions.
Findings:
A review of the facility document titled, RESIDENTS WITH ENHANCED BARRIER PRECAUTIONS,
undated, indicated, Residents 4, 6, 7, 8, 18, 21, and 37 were on Enhanced Barrier Precautions.
On February 27, 2025, at 2:51 p.m., Residents 4, 6, 7, 8, 18, 21, and 37 rooms did not have EBP signage
posted by the door. There was no indication of which bed was on EBP.
On February 26, 2025, at 9:24 a.m., during concurrent interview and observation with Resident 7 and
Certified Nurse Assistant (CNA) 1, CNA) 1 stated Resident 7 had a wound on the right foot and was on
EBP. CNA 1 further stated there were no signage indicating the required PPE or the specific precautions for
the resident. CNA 1 stated without prior communication with the Director of Nursing, she might have been
unaware of the necessary precautions. CNA 1 stated EBP signage should be posted by the door.
On February 26, 2025, at 9:30 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1
stated Resident 7 was on EBP for a right foot wound and that appropriate EBP signage should have been
posted by the door.
On February 27, 2025, at 3:19 p.m., during an interview with the Infection Preventionist (IP), the IP stated
the facility's practice was to place residents with conditions such as wounds, indwelling devices, or those
undergoing dialysis on EBP. The IP stated, the signage was to inform staff and visitors of the necessary
isolation precautions and the protective equipment required to prevent the spread of infection. The IP
stated, EBP signage should have been posted for Residents 4, 6, 7, 8, 18, 21 and 37's room.
A review of the facility policy and procedure titled, infection Control-Enhanced Barrier Precautions, dated
October 2022, indicated .Enhanced Barrier Precaution are an infection control intervention designed to
reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 14 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555383
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Blythe Post Acute LLC
285 West Chanslor Way
Blythe, CA 92225
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Based on observation, interview, and record review, the facility failed to ensure multi-resident bedrooms
provided the required minimum of 80 square feet per resident in seven out of 17 rooms (Rooms 5, 6, 8, 9,
10, 11, and 12).
This failure had the potential to negatively affect the residents' quality of life.
Findings:
A review of the facility's, Census, dated, February 25, 2025, indicated, all resident bedroom assignments,
and the number of resident's sharing each room.
During initial tour of the facility on February 25, 2025, Rooms 5, 6, 8, 9, 10, 11, and 12 were observed to
contain three beds each, with three residents per room.
On February 25, 2025, at 10:52 a.m , an interview was conducted with the Administrator (AM). The AM
stated, the facility had to provide residents with bedrooms measuring at least 80 square feet per resident in
a multi-resident rooms. The AM further stated that Rooms 5 through 12 each measured 239 square feet,
accommodating three residents per room, resulting in approximately 79.6 square feet per resident. The AM
stated, these rooms did not meet the required 80 square feet per resident.
The AM further stated, there have been no complaints from residents or staff regarding insufficient living
space or not providing care due to room size. The AM stated, Rooms 5, 6, 8, 9, 10, 11, and 12 did not
contain bariatric equipment or excessive personal items that could impact the available space.
On February 25, 2025, at 10:52 a.m. the AM requested a continued room waiver for rooms 5, 6, 8, 9, 10,
11, and 12 to accommodate all residing residents.
During the survey days from February 25, 2025, to February 28, 2025, no negative impacts on the health,
safety, and comfort of the residents were observed. Residents residing in Rooms 5, 6, 8, 9, 10, 11, and 12
who were interviewed stated they were comfortable in their rooms.
A review of the facility Policy & Procedure, titled, Bedrooms, revised, May 2017, indicated, . Policy
Statement All residents are provided with clean, comfortable and safe bedrooms that meet federal and
state requirements . Policy Interpretation and Implementation 1. Bedrooms measure at least 80 square feet
of space per resident in double rooms, and at least 100 square feet of space in single rooms .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555383
If continuation sheet
Page 15 of 15
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Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
FAQ · About this visit
Common questions about this visit
What happened during the February 28, 2025 survey of BLYTHE POST ACUTE LLC?
This was a inspection survey of BLYTHE POST ACUTE LLC on February 28, 2025. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BLYTHE POST ACUTE LLC on February 28, 2025?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.