Inspection·December 24, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of physical abuse within two hours to the California Department of Public Health (CDPH) after the facility was made aware of the allegation, for one of four sampled residents (Resident 1). This failure had the potential to result in further abuse of Resident 1, affecting the resident's emotional and psychosocial well-being. Findings: On December 22, 2024 at 2:07 p.m., CDPH received a fax (facsimile - telephonic transmission of scanned-in printed material) report involving a complaint allegation of physical abuse for Resident 1. On December 2, 2024, at 9:31 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder (a mental illness affecting mood and concentration). A review of Resident 1's Minimum data Set (an assessment tool) dated October 10, 2024, indicated a Brief Interview for Mental Status (used to identify the cognitive condition of a resident) score of 14 (cognitively intact). A review of Resident 1s eINTERACT Change in Condition Evaluation, dated November 21, 2024, indicated, . At around 4 p.m. CNA (Certified Nurse Assistant) reported patient refused to take a shower .patient complained of pain when she was brushing tangle hair . A review of Resident 1s SBAR Communication Form, dated November 22, 2024, indicated, . at approximately 0245 (2:45 a.m.) resident verbalized to staff that allegedly abused during PM shift .Resident stated alleged abuse occurred when staff attempted to shower her. A Review of Resident 1 Progress Notes, dated November 22, 2024 at 6:37 a.m., indicated .Called CDPH .in regards to allegation of abuse . On December 2, 2024, at 10:05 a.m., during an interview with Resident 1, she stated on November 21, 2024 around 4:30 p.m., during her scheduled shower, CNA 1 brushed and pulled her hair hard. (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: 555923 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 555923 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Temecula Healthcare Center 44280 Campanula Way Temecula, CA 92592 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)