F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was
transferred with two person assist using the Hoyer lift (a portable total patient lifting tool to assist in
transferring patients in and out of bed), from his Geri-chair (a large padded chair that can recline and is
used for people with limited mobility), to bed.
This failure had the potential to result in an injury to Resident 1.
Findings:
On March 19, 2024, at 10:59 a.m., an unannounced visit to the facility was condcuted to investigate quality
care issues.
A review of Resident 1's medical records indicated he was admitted on [DATE], with diagnoses which
included CVA (cerebral vascular accident – stroke), affecting left side non-dominate, depression (a
mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus type 2 (a
chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin
— a hormone that regulates the movement of sugar into the cells — or doesn't produce
enough insulin to maintain normal sugar levels), osteoarthritis (a progressive disorder of the joints caused
by gradual loss of cartilage and resulting in the development of bony spurs and cysts at the margins of the
joints), epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss
of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and contracture
(a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity
and rigidity of joints) left knee.
A review of Resident 1's History and Physical dated June 15, 2023, indicated he had the capacity to
understand and make decisions.
On March 19, 2024, at 11:59 a.m., observed Resident 1 in his room in a Geri-chair. Observed the Certified
Nursing Assistant, (CNA) with a Hoyer lift, entered Resident 1's room. The CNA shut the door behind her.
On March 19, 2024, at 12:25 p.m., Resident 1's door opened. Resident 1 was in bed, and the CNA wheeled
the Hoyer lift out of Resident 1's room into the hallway.
On March 19, 2024, at 12:25 p.m., an interview was conducted with the CNA. The CNA stated that she was
assigned to Resident 1. The CNA stated that she used the Hoyer lift to transfer Resident 1 back
(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:
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
04/09/2024
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
into bed. The CNA stated that the Hoyer lift should be operated with two people to safely transfer residents.
The CNA stated that she did not have another person assist with the Hoyer lift to transfer Resident 1 into
bed.
On March 19, 2024, at 12:28 p.m., an interview was conducted with Resident 1. Resident 1 stated he knew
the staff should be using two persons with the Hoyer lift.
On March 19, 2024, at 1:01 p.m., an interview was conducted with CNA 2. CNA 2 stated the Hoyer lift
should be used with two staff members.
On March 19, 2024, at 3:03 p.m., an interview was conducted with the Director of Nursing, (DON). The
DON stated that the Hoyer lift required two persons to operate it.
A review of Resident 1's Care Plan revised March 19, 2024, indicated .Focus .The resident has an ADL
self- care deficit .performance deficits .Interventions .FMP TRANSFER: The resident requires Mechanical
Lift with 2 staff assistance or may use hoyer lift for transfers .
A review of the facility's policy and procedure titled Lifting Machine, Using a Mechanical revised July 2017,
indicated .The purpose of this procedure is to establish the general principles of safe lifting using a
mechanical lifting device .General Guidelines .1. At least two (2) nursing assistants are needed to safely
move a resident with a mechanical lift .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055223
If continuation sheet
Page 2 of 2
