Inspection·February 27, 2024

F 0812 -four bunches of celery with no date; and Level of Harm - Minimal harm or potential for actual harm -two turkeys, approximately 20 pounds of chicken, seven 5-pound tubes of ground hamburger, and three beef briskets with no labels indicating the name of the foods and when thawing was started and to be completed. Residents Affected - Some During the inspection a concurrent interview was conducted with the DS and the RD. The DS and the RD stated the food should be labeled when it arrived at the facility and when it was opened. The DS and the RD stated expired food and/or food that had passed its best buy date needed to be removed and disposed of so the food would not be available for the residents. The DS and the RD stated the food items found should not have been available for resident use. The DS stated the thawing meat needed to be labeled when it was placed in the refrigerator and when thawing should be completed. The DS stated none of the thawing meat was labeled. The DS stated it was important to label thawing meats to prevent spoilage. On February 27, 2024, at 12:30 p.m., after the kitchen inspection was completed, the DS stated the food carts should be free from any breaks or open cracks for sanitation purposes and to prevent food borne pathogens (bacteria that can grow on surfaces that can lead to serious illnesses). The DS stated there were five meal carts used at the facility and they were wiped clean after each meal service. The DS stated the meal carts were out in the facility for lunch service. On February 27, 2024, at 12:50 p.m., the Dish Machine Temperature Log dated February 2024, was reviewed with the DS and the RD. During a concurrent interview, the DS stated the dishwasher was a low temperature dishwasher and used chemicals to maintain sanitation. The DS stated the dishwasher chemical concentrate needed to be checked and documented three times a day, before meal service. The RD and DS stated the facility log for February was missing several entries. The RD and the DS stated 14 of the evening checks of the dish machine temperature log were blank. The DS and the RD stated it was important for the dish machine to be checked as scheduled to maintain sanitation of resident utensils and dishes. On February 27, 2024, at 2:05 p.m., a follow up kitchen inspection was conducted with the DS and the RD of the facilities five food carts. Two of the yellow food carts were observed with white duct tape on the inside of both doors, and around the locking mechanisms. The tape appeared to be peeling and missing in several areas. Edges of the tape appeared to be lifting and curled up with brown edges. The DS and the RD stated there should not be any cracks or open areas on the food carts. The DS and the RD stated the food carts should not have duct tape. The DS and the RD stated the duct tape was a potential hazard for food borne pathogens to grow and could not be cleaned and sanitaized. The RD stated it was important for the food carts to be free from areas that could not be cleaned and sanitized. Review of the facility document titled, General Receiving of Delivery of Food and Supplies dated 2018, indicated, .Label all items with the delivery date or a use-by date . Review of the facility document titled, Storage of Food and Supplies dated 2020, indicated, .Labels should be visible, and the arrangement should permit rotation of supplies so that oldest items will be used first. All food will be dated-month, day, year. All food products will be used per the time specified .No food will be kept longer than the expiration date on the product .Dry food items .will be tightly closed, labeled and dated .Hoisin Sauce .Opened-Refrigerated .3 months .Dried fruit such as prunes & raisins .opened, refrigerated .1 month . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055223 If continuation sheet Page 2 of 3 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 055223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Jacinto Valley Post Acute 275 North San Jacinto Street Hemet, CA 92543 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Review of the facility document titled, Procedure for Refrigerated Storage dated 2019, indicated, .Frozen food should be left in a refrigerator to thaw .Once thawed, uncooked meat is to be used within 2 days . Review of the facility document titled, Food Preparation dated 2018, indicated, .POLICY: THAWING OF MEATS .PROCEDURE .In a refrigerator .Label defrosting meat with pull and use by date . Residents Affected - Some Review of the facility document titled, Dish Washing dated 2018, indicated .All dishes will be properly sanitized through the dishwasher .A temperature log (and chlorine log for low-temperature machines) will be kept and maintained by the dishwashers to assure that the dish machine is working correctly. This log will be completed each meal prior to any dishwashing .Low-temperature machine .The proper chlorine level is crucial in sanitizing the dishes . Review of the facility document titled, Sanitation dated 2018, indicated, .The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for proper preparation, serving and storing of food .All equipment shall be maintained as necessary and kept in working order .Employees are to alert .immediately .any equipment needing repair .equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055223 If continuation sheet Page 3 of 3