Health inspection·July 8, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on interview and record review, the facility failed to ensure a safe water system was in place for 44 residents when: Residents Affected - Few 1. The high temperature alarm (a mechanism to alert the staff when water temperatures exceed 120 degrees Fahrenheit [°F]) was not working. This failure had the potential to place the residents at risk of scalding from high temperature water. 2. The facility did not monitor hot water temperature for three out of 12 days for the month of June 2025. This failure had the potential to contribute to unsafe conditions without timely staff awareness. Findings: 1. On July 3, 2025, at 10:30 a.m., during an interview with the Maintenance Supervisor (MS). The MS stated, the facility's procedure was to monitor hot water temperatures daily. The MS stated, the high temperature alarm was used to ensure that water used by residents did not exceed 120°F. The MS further stated, the high temperature alarm at the nurses station was currently not working. On July 3, 2025, at 1:30 p.m., during an interview with the Administrator (ADM), the ADM stated to ensure resident safety, the MS was responsible for daily hot water monitoring and the high temperature alarm should be functioning. 2. A review of facility document titled, Daily Hot Water Temperature Record, Month of June 2025, indicated blank entries on the following dates: - June 1, 2025; - June 6, 2025; and - June 7, 2025. On July 3, 2025, at 10:30 a.m., during a concurrent interview and record review with the Maintenance Supervisor (MS), the MS stated no hot water temperature checks were performed on June 1, June 6, and June 7, 2025. The MS stated, it should have been checked, since it's a risk not knowing if the (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 2 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 07/08/2025 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)