Health inspection·June 16, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and document residents' vital signs (an assessment of resident's physiological stability, including a blood pressure, pulse, temperature and oxygen saturations) prior to non-emergent transport to a general acute care hospital (GACH) for two of three sampled residents (Residents 1 and 2). Residents Affected - Few This failure had the potential to result in unrecognized changes in condition and adverse outcomes during transport. Findings: On May 8, 2025, at 10:25 a.m., an unannounced visit was made to the facility for a quality-of-care issue. 1. A review of Resident 1's, Personal Information, dated May 8, 2025, indicated, resident was admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease (a lung disease that cause airflow obstruction). Further review indicated Resident 1 had a Brief Interview for Mental Status (short structured tool to assess cognitive function) score of 15 (intact cognition). On May 8, 2025, at 1:40 p.m., an interview was conducted with Resident 1, who verified, she was recently transferred out of the facility for further evaluation at GACH (from April 23 - 27, 2025). A review of Resident 1's, Progress Notes, dated, April 23, 2025, at 7:30 a.m., indicated, . (Resident 1) (complained of) increased difficulty breathing and . edema (swelling caused by excess fluid buildup in tissue) to (both lower legs). Requesting to go to GACH for evaluation. Taken via wheelchair . (new orders) received for transfer . Further review indicated no documented vital signs were taken prior to the transfer to GACH on April 15, 2025. A review of Resident 1's, Notice of Transfer/Discharge, dated, April 23, 2025, untimed, indicated, resident was transferred to GACH on the same day on April 23, 2025. A review of Resident 1's vital signs, indicated, the last assessment of vital signs before transferring to GACH on April 23, 2025, were documented on April 22, 2025, between the hours of 2 p.m. and 10 p.m. and were as follows: - Blood pressure: 109/64 Page 1 of 3 555383 555383 06/16/2025 Blythe Post Acute LLC 285 West Chanslor Way Blythe, CA 92225

F 0684 - Pulse: 78 Level of Harm - Minimal harm or potential for actual harm - Temperature: 96.8 - Respirations: 20 Residents Affected - Few - O2 (oxygen) Saturation: 93%. On May 8, 2025, at 3:07 p.m., an interview was conducted with the Director of Nursing (DON), who stated, a resident's vital signs provide a baseline of their over health status and are used to evaluate a resident's (physiological) stability, prior to transport. The DON stated, it is her expectations that nursing staff obtain and document a set of resident's vital signs prior to any transfer to GACH. The DON stated, if a residents' vital signs were not stable, they would be transported for evaluation via ambulance, not the facility van. On June 16, 2025, at 2:47 p.m., an interview was conducted with the DON, who stated, vital signs should be taken at least one hour prior to hospital transfer and documented in the medical record. 2. A review of Resident 2's medical records, titled, Resident Information, dated, May 8, 2025, at 10:53 a.m., indicated, resident was admitted to the facility on [DATE], with a diagnosis of heart failure, and muscle weakness. A review of Resident 2's BIMS indicated a score of 10 (Moderate impairment). On May 8, 2025, at 1:46 p.m., an interview was conducted with Resident 2, who verified, she had recently been transferred to a general acute hospital for further evaluation from April 30 to May 4, 2025. A review of Resident 2's, Nurses Progress Notes, dated, April 30, 2025, at 0800, indicated, . (Resident 2) (complained of) shortness of breath, increased weakness, not answering questions appropriately and lethargic . (New Orders) received for transfer to (General Acute Care Hospital {GACH}). Taken via (wheelchair) Van to (GACH) . Further review of Resident 2's record indicated no set of vital signs was documented prior to Resident 2's transfer to GACH on April 30, 2025. A review of Resident 2's, Notice of Transfer . , dated, April 30, 2025, untimed, indicated resident was transferred to GACH on April 30, 2025. A review of Resident 2's, vital signs documentation, indicated, the last recorded set of vital signs before transfer to GACH was from April 29, 2025, between the hours of 2 p.m., and 10 p.m.: - Blood Pressure: 134/75 - Temperature: 97.7 - Pulse: 62 - Respirations: 16 555383 Page 2 of 3 555383 06/16/2025 Blythe Post Acute LLC 285 West Chanslor Way Blythe, CA 92225

F 0684 - O2 Saturation: 94%. Level of Harm - Minimal harm or potential for actual harm On May 8, 2025, at 3:07 p.m., an interview was conducted with the Director of Nursing (DON), who stated, a resident's vital signs provide a baseline of their over health status and are taken to evaluate a resident's (physiological) stability, prior to transport. The DON stated, it is her expectations for nursing staff to take and document vital signs in the resident's medical record prior to transfer to GACH. The DON stated, if the residents' vital signs were not stable, the resident should be transported via an ambulance, not the facility VAN. Residents Affected - Few On June 16, 2025, at 2:47 p.m., an interview was conducted with the DON, who stated, the nursing staff are expected to obtain and document a set of vital signs at least one hour prior to transport to the hospital for further evaluation. A facility Policy & Procedure, titled, Change in a Resident's Condition or Status, revised, May 2017, indicated, . 1. The nurse will notify the resident's Attending Physician or Physician on call when there has been a (an): . g. need to transfer the resident to a hospital/treatment center . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . 555383 Page 3 of 3