Inspection·January 23, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for one of two residents, Resident 1, a medication ordered by the doctor was given as prescribed. This failure had the potential for Resident 1 to have hypokalemia (low potassium level in the blood) which could cause Resident 1 to experience muscle cramps and abnormal heart rhythms. Findings: On January 22, 2024, at 9:28 a.m., at the north unit of the facility, a med pass (administration of medications) observation was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 prepared Resident 1 ' s medications which included potassium chloride. LVN 1 placed the box of potassium chloride oral packets, which were labeled for Resident 1 and dated October 24, 2024, on top of the medication cart. LVN 1 removed one oral potassium chloride packet from the box, prepared it, and administered it to Resident 1. A review of Resident 1 ' s medical record indicated she was admitted to the facility on [DATE], with diagnoses which included stroke with right sided weakness. A review of Resident 1 ' s physician ' s orders indicated .Potassium Chloride Oral Packet 20 MEQ (mEq-milliequivalent, a unit of measurement used to express number of electrolytes and medications) .Give 20 mEq by mouth one time a day for hypokalemia admin (administer) it with food/snack and full glass of water or other juices . was ordered on July 16, 2024. On January 22, 2024, at 10:00 a.m., during an interview with LVN 1, LVN 1 was asked to retrieve the box of potassium chloride packets for Resident 1. LVN 1 stated the box indicated it had 30 packets inside, it was opened on October 24, 2024. LVN 1 was asked to count how many packets were still in the box, LVN 1 stated there were 15 packets in the box. LVN 1 stated all of the packets should have been used by at least November 23, 2024. LVN 1 stated maybe Resident 1 refused the medication even before it was prepared for her, with the other licensed nurses. On January 22, 2024, at 10:10 a.m., a review of Resident 1 ' s Medication Administration Record for October and November 2024 was conducted with LVN 1. There was no documented evidence that Resident 1 refused potassium chloride packets in October and November 2024. LVN 1 stated the potassium chloride oral packets were administered to Resident 1 in October and November 2024. On January 23, 2024, at 4:15 p.m., during an interview, LVN 2 stated there were no other residents (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 4 Event ID: 055223 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 01/23/2025 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)