San Jacinto Valley Post Acute

In the surveyor’s words

From the most serious findings on record at San Jacinto Valley Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF689Apr 14, 2026

  Based on observation, interview and record review, the facility failed to ensure an exit door (EXD 1), located along (name of street), was readily accessible and unobstructed for 24 of 24 residents when the door handles were secured with a zip tie.This failure resulted in an obstructed exit door and had the potential to result in a delay or prevent the residents from exiting the facility during an emergency, such as a fire.Findings:On April 14, 2026, at 10:07 a.m., during a concurrent observation and interview, Resident 1 was awake and alert, sitting in his wheelchair near EXD 1. Resident 1 stated EXD 1 used to be the main entrance. Resident 1 stated he observed EXD 1 door handles were zip tied on two separate occasions. […]

• No harm, potential for more than minimal, patternF689Jan 30, 2026

  Based on observation, interview, and record review, the facility failed to implement, review, and re-evaluate care plan interventions to prevent falls two of 19 residents reviewed (Resident 20 and Resident 86).This failure resulted in Resident 20 and Resident 86 experiencing multiple falls and had the potential for Resident 20 and Resident 86 to sustain avoidable injuries. Findings:On January 26, 2026, at 3:59 p.m., a concurrent observation and interview was conducted with Resident 20. Resident 20 was observed alert and oriented, in a low bed with floor mat, receiving gastrostomy (medical device inserted into the stomach for administering formula, fluids, and medication) feeding. […]

• No harm, potential for more than minimal, patternF755Jan 30, 2026

  Based on observation, interview, and record review, the facility failed to ensure provision of safe and effective pharmaceutical services to meet the needs of the residents when: Medications with holding parameters were not administered according to the physician's orders for three of four reviewed residents (Resident 2, 3, and 109) on blood pressure (BP) medications. This failure had the potential to significantly lower blood pressure to cause dizziness, confusion, fainting and a fall.Findings: 1. On January 28, 2026, a review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF761Jan 30, 2026

  Based on observation, interview, and record review, the facility failed to ensure proper storage of medications in accordance with the facility policy and procedures (P&P) and manufacturer's specifications when: 1. One expired house supply medication (medications kept for general use for residents, rather than dispensed or labeled for a specific resident) was stored in one of two reviewed medication rooms (North Medication Room); and2. An expired medication was kept in stock in one of five reviewed medication carts (Middle Medication Cart) along with other active medications. These failures had the potential for the residents to receive expired or ineffective medications, which could lead to medication errors and compromised treatment outcomes.Findings: 1. […]

• No harm, potential for more than minimal, patternF812Jan 30, 2026

  Based on observation, interview, and record review, the facility failed to ensure food items readily available for use were stored in the freezer with a label of open date or expiration date. This failure had the potential to result in foodborne illness to a vulnerable facility population.Findings:On January 26, 2026, at 1:46 p.m., during the initial tour of the kitchen, an observation and concurrent interview was conducted with the Dietary Supervisor (DS). One whole piece of roast beef (approx. 7 lbs.) was observed in the freezer, readily available for use. The roast beef was observed with no open date, no use-by date, and no expiration date. The DS stated all items stored in the refrigerator or the freezer should have a label of open date, a use-by date, or an expiration date. […]