Health inspection·April 9, 2024

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 Page 1 of 2 055223 055223 04/09/2024 San Jacinto Valley Post Acute 275 North San Jacinto Street Hemet, CA 92543

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 . 055223 Page 2 of 2