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 (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 3 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 06/16/2025 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)