Inspection·January 28, 2025

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 observation, interview, and record review, the facility failed to ensure an environment free of accident hazards was provided, when the bed alarm was not implemented for one of five residents reviewed for falls (Resident 1). In addition, Resident 1's fall risk assessment was not updated to reflect newly identified fall risks discussed during the interdisciplinary team (IDT - a group of healthcare professionals who work together for the common goal of the resident) meeting. These failures had the potential to result in further falls and injuries for Resident 1. Findings: On January 28, 2025, at 12:58 p.m. Resident 1 was observed to be sitting in a chair at the bedside. No bed alarm was observed on the bed or chair. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included repeated falls, unspecified dementia (memory loss). A review of Resident 1's Minimum Data Set, dated December 30, 2024, indicated Resident 1's Brief Interview for Mental Status score was 7 (severely impaired cognitive status). A review of Resident 1's SBAR, (Situation-Background-Assessment-Recommendation- communication tool) dated January 18, 2025, indicated, .Patient (Resident 1) was found sitting on the floor beside her bed, when asked what happened patient stated that she was trying to take herself to the bathroom. When asked why she did not put on her call light, she said she thought she could do it by herself . A review of Resident 1's Care Plan initiated on January 18, 2025, with a revision on January 20, 2025, indicated, .Resident had an unwitnessed fall, was observed on the floor .review information related to the fall and conduct a root cause analysis to determine possible cause of fall. Alter/remove any potential causes if possible to determine new intervention .electronic alarm to (Specify: bed, wheelchair) .check functionality and placement every shift .alarm assessed as a possible restraint and does not prevent resident from rising . A review of Resident 1's IDT (Interdisciplinary Team - a group of healthcare professionals who work together for the common goal of the resident) Post Accident/Fall document, dated January 20, 2025, indicated, .Determined follow-up measures that are needed to reduce the risk of reoccurrence .bed alarm .updated post fall evaluation .new resident specific intervention initiated .bed alarm .updated post fall evaluation . (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 01/28/2025 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)