Blythe Post Acute LLC

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents reviewed for abuse (Resident 1) was free from verbal abuse when a Certified Nurse Assistant (CNA) yelled profanity toward Resident 1. This failure had the potential to cause psychosocial distress, fear, humiliation, loss of trust, emotional harm, behavioral symptoms, and decline in psychosocial well-being.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an allegation of verbal abuse was reported immediately, but not later than two hours after the allegation was witnessed, for one of three residents reviewed for abuse (Resident 1). This failure delayed initiation of the facility's investigation and implementation of timely measures to ensure resident safety, placing Resident 1 at risk for potential ongoing abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe use of medications when:Controlled substance (controlled medications, those with high potential for abuse and addiction) waste procedures were not implemented for five of seven randomly selected residents (Resident 50, 2, 5, 29, and 24);The Controlled Substance Records (CSR, accountability records) for two of four randomly selected residents (Residents 24 and 2) did not reconcile with the Medication Administration Records (MAR, daily documentation record used by nurses to document medications and treatments given to a resident); andPrescription medications were used for multiple residents when one medication at one of one reviewed medication carts was shared between two residents (Residents 10 and 16). [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 11.67% when seven medication errors occurred out of 60 opportunities during the medication administration observation for five of ten residents (Residents 44, 42, 3, 13, and 2). These failures resulted in medications not given according to the physician's orders and had the potential for residents to experience side effects such as loose stools or inadequate management of conditions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food items were stored in a sanitary manner in two of two refrigerators (Refrigerator 1 and Resident's Refrigerator), three of four freezers (Freezers 1, 2, and 3), and the kitchen counter by failing to:a. Label received food items,b. Indicate the use by date (the last date recommended for the use of the product) and/ or the open date,c. Discard food beyond the use by date. These deficient practices had the potential to cause food-borne diseases to 47 residents receiving food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to provide a convenient venue to both parties in the Arbitration Agreement to four of 23 sample residents (Residents 16, 26, 41, and 55). This deficient practice had the potential to prevent residents from resolving their dispute with the facility in a proper and convenient location.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) was free from unnecessary psychotropic medications (medications that affect brain activities associated with mental processes and behavior) when:One resident (Resident 2) received an as needed (PRN) antipsychotic medication (type of psychotropic medication to treat mental illness) without required documentation of behavior or attempted non-pharmacological interventions (treatment or method used to improve symptoms without taking medication); and One resident (Resident 2) received an antipsychotic medication without specific targeted behavior. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Comprehensive admission Minimum Data Set (MDS - a federally mandated resident assessment tool) Assessment was not completed more than 14 days after admission for one of 18 sampled residents (Resident 24). This deficient practice had the potential to delay the care planning process to meet Resident 24's comprehensive and individualized care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized care plan for one of three residents (Resident 50), to address the behavior of removing the nasal cannula (NC-flexible tube to deliver oxygen into the nose) used for oxygen therapy. This failure had the potential to place Resident 50 at risk for ineffective oxygen therapy and potential respiratory compromise.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards when one of five sampled residents (Resident 8) did not have documentation to support a diagnosis of schizophrenia (a mental illness characterized by disturbances in thought) in a resident with dementia (memory loss that gets worse over time). This failure had the potential for unnecessary use of antipsychotic medications (medications to treat mental illness like schizophrenia).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered as ordered for one of three sampled residents (Resident 50), when the nasal cannula (NC- flexible tube to deliver oxygen into the nose) tubing was not positioned in the resident's nares (openings of the nose). This failure had the potential to result in ineffective oxygen therapy and potential respiratory compromise for Resident 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of ten residents (Resident 2) was free of a significant medication error when the facility did not give lacosamide (generic for Vimpat, seizure medication) doses to Resident 2 as ordered on four of 10 days. This failure had the potential for Resident 2 to experience worsening of her medical conditions, including seizures.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly close one of four metal dumpsters which exposed the overflowing trash inside. This deficient practice had the potential to attract pests which could spread disease to residents and staff in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure multi-resident bedrooms provided the required minimum of 80 square feet of livable space per resident in eight of 18 rooms (room [ROOM NUMBER], 6, 7, 8, 9, 10, 11, 12). This failure limited residents' available personal space and had the potential to affect residents' ability to move safely and freely within the room.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was developed for one of one resident reviewed for tobacco use (Resident 1) following her re-admission to the facility, despite a documented history of marijuana use. This failure had the potential to place the resident at risk for adverse health effects related to medical diagnoses, unsafe use or storage of marijuana, and smoke-related safety hazards.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four Certified Nursing Assistants reviewed (CNA 1) maintained an active State-approved CNA certification and current CPR certification (cardiopulmonary resuscitation - an emergency lifesaving procedure performed when the heart stops beating) before providing direct care to residents. This failure had the potential to result in unsafe and inadequate care to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe water system was in place for 44 residents when: 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.

Inspectors wroteBased 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). This failure had the potential to result in unrecognized changes in condition and adverse outcomes during transport.

Inspectors wroteBased on interview and record review, the facility failed for one of three sampled residents (Resident 1) to conduct a thorough investigation into Resident 1's allegation of abuse involving Certified Nursing Assistant (CNA 1) before allowing the alleged perpetrator to return to work. This failure had the potential to expose Resident 1 to further abuse and compromised the integrity of the abuse investigation process.

Inspectors wroteBased 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). This failure had the potential to expose a population of 44 residents to foodborne illnesses (illnesses resulting from eating contaminated food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices when: 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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). 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.

Inspectors wroteBased 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

Inspectors wroteBased 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)]. This failure had the potential to result in staff and visitors being unaware of necessary PPE requirements prior to entering rooms requiring isolation precautions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct and complete neurological assessment (neuro checks - assessment of neurological function and [LOC]-level of consciousness) for the first hour after an unwitnessed fall for one out of three sampled residents (Resident 1). This failure had the potential to result in serious consequences, including loss of consciousness, seizures (uncontrolled movements), and coma (unable to wake up) which could go undetected.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (Identified healthcare conditions, including individualized goals and interventions) addressing the use of an illegal drug (marijuana- mind-altering [psychoactive] drug) while at the facility, for two of three sampled residents (Residents 1 and 2). This failure has the potential to result in mismanagement of resident's medical health issues for Resident 1 and 2.

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor the change in condition for one of two residents (Resident 1). This failure had the potential to delay necessary treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' admission orders included all current medications, and the correct dosages for two out of three sampled residents (Residents 4 & 5) when: 1. Resident 4 ' s admission order for Sertraline (an anti-depressant medication) had an incorrect dosage; and 2. Resident 5 ' s admission orders did not include her asthma (a lung disease that causes difficulty breathing) inhalers, Symbicort (medication to help manage and prevent symptoms in residents with asthma) and albuterol (medication used to treat asthma). This failure resulted in: 1. Resident 4 receiving an incorrect dosage of Sertraline on September 6, 2024, which could result in worsening of depression. 2. Resident 5 not receiving physician orders for her asthma medications, which could result in breathing difficulties and worsening asthma symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective pest control program to address the presence of flies in the building. This failure resulted in flies in the facilities common areas and resident bedrooms potentially leading to infections, increase in health issues such as gastrointestinal infections or skin irritations to vulnerable population in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure an alleged abuse involving three of three residents reviewed (Residents 1, 2, and 3) were reported to the California Department of Public Health (CDPH) immediately or within 24 hours. This failure resulted in a delayed investigation of the alleged abuse causing a delay in implementation of corrective actions which placed the residents at risk for further abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat Resident 1's possessions with respect for one of four sampled residents (Resident 1), when facility did not store resident's electric wheelchair in a manner which would keep it clean and damage free. The failure had the potential to damage Resident 1's electric wheelchair, while in storage.

Inspectors wroteBased on observation and interview, the facility failed to provide for one of five sampled residents (Resident 2), services within reasonable accommodation of the resident's needs and preferences: 1. The facility did not have a working electric Hoyer lift, preferred by Resident 2 for transfer assists; and 2. The facility has one large Geri-chair which was unavailable for use by the resident because it was shared among multiple residents. These failures had the potential to exclude Resident 2 from being transferred out of bed, and sitting comfortably in a chair, while out of bed.

Inspectors wroteBased on interview and record review, the facility failed to coordinate cardiology specialty (specialty doctor that treats conditions related to the heart) care for one of three sampled residents (Resident 3), after a new diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm) on May 4, 2024. This failure had the potential to result in worsening cardiac (heart) function, stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), and/or other serious medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure for two of four sampled residents (Residents 1 and 3), were free of significant medication error when the prescribed Augmentin (amoxycillin and potassium clavulanate - drug used to treat bacterial infections in many different parts of the body (ear, lungs, sinus, skin, urinary tract) was not administered on three occasions for Resident 1 and on two occasions for Resident 3. This failure had the potential to worsen both residents' infections, leading to prolonged illness and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the diet order was followed according to the physician's order, for two of three sampled residents (Residents 2 and 3), when Residents 2 and 3 did not receive lemon pound cake on lunch meal tray on 7/1/2024 according to the diet ordered by the physician. These failures had the potential to result in compromising Resident 2 and 3's nutritional and medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required 80 square feet (sq ft) per resident (80 sq ft/resident) in a multi-resident bedroom, was met for 8 out of 18 rooms (Rooms 5, 6, 7, 8, 9, 10, 11, & 12). This failure had the potential to negatively affect the quality of life of the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice to resident of a pending room change for one of three sampled residents (Resident 3). This failure had the potential for Resident 3 to develop anxiety, confusion, and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain temperatures between 71 to 81 degrees Fahrenheit (F), with resident room temperatures in three of six sampled resident rooms, reaching 84.7 degrees F. This deficient practice resulted in discomfort for two of eleven sampled residents (Residents 1 and 2), and potential adverse health effects for residents, staff and visitors including dehydration (loss of body fluids), heat stress (a series of conditions where the body is under stress from overheating), and heat stroke (when the body can no longer control its temperature).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. The laundry staff transported the clean laundry uncovered; 2. Facility did not sanitize washer in between laundering. 3. The facility did not monitor for legionella (bacteria that can cause a severe from of pneumonia [lung condition]) in the water system annually. These failures potential to increased cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) which could result to increse infections to facility residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were provided information on how to file a grievance. This failure had the potential for residents to not be able to address their issues and voice their concerns which could worsen the existing problems.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of four residnets sampled (Residents 14, 24 and 33's) skin was monitored and assessed in accordance with the facility's policy and procedures. This failure had the potential for Residents 14, 24, and 33 to develop skin breakdown and or pressure injury (PI's- localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) affecting the residents overall health and wellbeing.

Inspectors wroteBased on interview and document and record review, the facility failed to ensure medication irregularities were identified during monthly medication regimen review (MRR) by the Consultant Pharmacist (CP) and recommendations were made to ensure appropriate use of medications when the CP did not make recommendations on the use of medications that were on the Beers Criteria for potentially inappropriate medications for elderly over the age of 65 for three of the five residents reviewed (Residents 5, 9 and 43). In addition, the facility failed to employ CP services for monthly review of all facility residents' medication regimen in October 2023. This had the potential to expose residents to severe adverse events from inappropriate medication use. [...]

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when the Dietary Supervisor (DSS) and [NAME] (CK) 1 was unable to accurately verbalize the cool down process for hot food and ambient food temperatures. This failure had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary environment, prepare, and served food in accordance with professional standards for food service safety when: 1. There were multiple areas in the kitchen and kitchen equipment that were not clean; 2. Multiple wet and moist pans and pots were stored and stacked on top of each other; 3. Multiple chopping boards had brown-yellowish discoloration and multiple deep cuts and indentations; 4. There was a 1/3 open container of salsa found on the kitchen preparation counter left at room temperature; 5. The inside of the ice machine had a black goo-like grime; and 6. The resident refrigerator had no thermometer gauge and no temperature monitoring. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, one (1) microwave oven, two (2) bottom oven shelves, four (4) oven door hinges, and one (1) dry storage room shelf were maintained in a safe operating condition. These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident's share of cost and amount of charges for the items and services covered by Medicare (federal health insurance for anyone aged 65 and older)/Medicaid (federal and state program that gives health coverage to some people with limited income and resources), for one of four residents reviewed (Resident 43). This failure had the potential to result in confusion and frustration for Resident 43, affecting his psychosocial and mental wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate assessments were conducted for two of three residents reviewed for resident assessment (Resident 33 and 42), 1. Resident 33's functional impairment of the upper extremities and lower extremities. This failure had the potential to affect management of care for Resident 33's current functional impairment which could cause further decline in mobility; and 2. Resident 42 had no natural teeth. This failure resulted for Resident 42 not receiving the appropriate level of care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for eight consecutive hours in a 24-hour period for January 21, 2024, and January 28, 2024. This failure had the potential to adversely affect oversight and direction regarding residents' quality of care and quality of life directly impacting overall health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility's policies and procedures were developed and implemented to track accurately the movement of controlled substances (CS) and to fully account for use of all CS to minimize the time and loss of diversion. Two out of three residents' medical record did not accurately account for removal and administration of CS. This had the potential for drug diversion by impaired staff caring for the residents.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician order when the medication Humalog Injection Solution (Insulin Lispro) a rapid-acting insulin was administered to the resident at a lower dose, for one of one resident reviewed for insulin (Resident 26). This failure had the potential for the medication to inadequately control resident's blood sugar level leading to hyperglycemia (high blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental appointment for dentures to a resident without dentition for one of one resident reviewed for dental (Resident 42). This failure had the potential to result in inadequate chewing, oral health issues such as gum disease.

Inspectors wroteBased on interview and record review the facility failed to: 1. Provide a safe environment to help prevent falls, as Resident 3's bedrails were not up, per doctor's (Dr's) orders, prior to his unwitnessed fall on October 12, 2023. 2. The facility failed to identify Dizziness, as a resident specific fall risk, prior to Resident 4's unwitness fall on October 9, 2023, and failed to incorporate Resident 3's history of Feeling Dizzy, into his resident-centered ' Falls care plan, per facility's Policy & Procedure (P&P), Falls and Fall Risk, Managing. These failures could have resulted in Resident 3 & Resident 4, experiencing additional falls, resulting in injuries.

Inspectors wroteBased on interview and record review, the facility failed to assure a pain re-assessment was completed, after Resident 2 received Tylenol 650mg for complaints of back pain, after an unwitnessed fall on October 24, 2023. This failure could have led to Resident 2 continuing to experience unrelieved back pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a properly functioning call light system in Resident1's bathroom, which did not activate each time the call light cord was pulled. This failure had the potential to delay staff's assistance in Resident1's bathroom, when the improperly functioning call light cord was pulled.

Inspectors wroteBased on interview and record review, the facility failed to provide monitoring on a resident who wandered to other resident's room, for one of three sampled residents (Resident 1). This failure resulted in an allegation of physical abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the licensed nurse conducted an assessment and monitoring of the purplish black discoloration (bruise) observed on the right hand, for one of three sampled residents (Resident A). This failure had the potential to result in delayed provision of care and treatment for Resident A's skin condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Certified Nursing Assistant (CNA) who observed a new skin discoloration (bruise) on the resident's left thigh documented and notified the licensed nurse of a change of condition, for one of three residents reviewed (Resident 1). This failure had the potential for the resident to experience a delay in treatment and further compromise resident's physical and emotional wellbeing.

Inspectors wroteThe facility failed to complete a 5 day summary and an abuse investigation in a timely manner, after accusations of verbal abuse towards Resident 1 which were reported to the facility Administrator. This failure had the potential to subject Resident 1 to further incidents of verbal abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment were consistently provided. In addition, the facility failed to reassess and to monitor weekly the status of the open wound on the left side of the forehead for one of the three sampled resident (Resident 1). These failures resulted in the facility licensed nurses unaware on the changes in the resident's left forehead open wound causing a delay in the provision of an appropriate treatment. Resident 1's open wound on the left forehead was noticed with maggot infestation (parasitic skin infestation caused by the larvae [maggots]of certain fly species) on May 20, 2023; and the resident had to be transferred to the general acute care hospital (GACH) for evaluation. [...]

Inspectors wroteThe facility failed to maintain an effective pest control program, to prevent the presence of flies within the building. This failure had the potential to result in flies infestation inside the facility, which could negatively impact the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the required air temperature ranging from 71 to 81 degrees Fahrenheit inside the resident's rooms on multiple occasions. This failure increased the risk for dehydration and could negatively affect the residents' already compromised health condition.