Inspection·September 23, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accurate documentation of an incident for one of four sampled residents (Resident 3), when the facility did not document a verbal altercation and related behaviors in the medical record.This failure had the potential for events to go unreported, increasing the recurrence, inadequate monitoring, and poor resident outcomes.Findings:On September 9, 2025, at 11:13 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse.A review of Resident 3's medical records indicated resident was admitted on [DATE], with diagnoses of monoplegia, (paralysis restricted to one limb or region of the body), of lower limb following cerebral infarction, (stroke), affecting left non-dominant side.A review of Resident 3's History and Physical dated June 28, 2025, indicated .doing well overall. In goodspirits (sic).A review of Resident 4's medical records indicated resident was admitted on [DATE], with diagnoses of displaced intertrochanteric fracture of right femur, (broken hip), subsequent encounter for closed fracture with routine healing, 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), and major depressive disorder, (a mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 4's History and Physical dated August 3, 2025, indicated resident had the capacity to make decisions.On September 9, 2025, at 11:47 a.m., during an interview with Resident 4, Resident 4 stated Resident 3 was bumping her wheelchair into everything and appeared agitated. Resident 4 stated that she overheard Resident 3 on the phone threatening to beat someone up. Resident 4 stated she put on her call light, and staff removed Resident 3 from the room. On September 9, 2025, at 1:24 p.m., during an interview with Resident 3, Resident 3 admitted that she wanted to beat up Resident 2, her previous roommate. Resident 3 denied intending to beat up Resident 4. On September 9, 2025, at 1:35 p.m., during an interview with the Licensed Vocational Nurse, (LVN), the LVN stated that when a resident is involved in a verbal altercation, they document a Change of Condition in the medical records. On September 9, 2025, at 1:38 p.m., during an interview with the Assistant Director of Nursing, (ADON), the ADON stated that Resident 3 had a verbal altercation with Resident 2 and was moved to a new room with Resident 4. The ADON stated that Resident 4 overheard Resident 3 on the phone talking about the altercation with Resident 2, earlier in the day. On September 9, 2025, at 3:23 p.m., during an interview with the Certified Nursing Assistant, (CNA 1), CNA 1 stated that on September 4, 2025, Resident 3 was moved from another room due to an altercation. CNA 1 stated that Resident 3 was upset, cursing and yelling from the previous altercation with Resident 2. CNA 1 stated she stepped away from the room and noticed Resident 4 had put on her call light, responded to the call light, and found Resident 4 crying, stating that she overheard Resident 3 was going to beat her ass CNA 1 notified the Registered Nurse and moved Resident 4 to a different room. On September 9, 2025, at 4:38 p.m., during an interview and record review with the Director of Nursing, (DON), the DON reviewed Resident 3's progress notes and confirmed there was no documentation of the incident with Resident 4. There was no evidence of documentation in Resident 3's medical records regarding the incident with Resident 4.A review of Resident 4's eINTERACT SBAR Summary for Providers dated September 4, 2025, indicated .Nursing observations, evaluation, and recommendations are: [Resident 4's room number] Call light was on and attended call light noted patient emotionally distress and crying r/t [related to] new room mate, (sic). According to [Resident 3], roommate went to her bed andtouch [sic] her bed. Roommate was on the phone saying (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555923 If continuation sheet Page 2 of 3 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 09/23/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete I am gonna beat her up. Separated patient and have a CNA watch them to prevent further incident while CN [charge nurse] informed RN [Registered Nurse] that [Resident 4] and roommate [Resident 3] are not compatible. Case Manager talked to [Resident 3] and said that she was talking on the phone about her old roommate in [room number].A review of Resident 4's IDT Note dated September 4, 2025, at 8 p.m., indicated Late Entry: Clinical Event Type:: Alleged Verbal AltercationDate and Time of Event:: 9/4/25 at around 6pm. Root Cause Analysis (RCA). Include Potential Underlying Cause(s)/Contributing Factor(s):: At around 6pm, the assigned LN [licensed nurse] and CNA reported to the writer that patient and her roommate are not compatible. Patient was crying after hearing her roommate on the phone saying she's going to beat her up. Writer went to the room, saw CM [case manager] speaking with theroommate (sic) and also social services speaking with the patient to get her statement. DON, [Director of Nursing], ADON, [Assistant Director of Nursing], Administrator, and Social Services notified. LN also reported that patient stated that her roommate slapped her bed, however roommate denied this. Patient's roommate clarified that she was on the phone talking about her previous roommate. Shortly after, patient was moved to a different room and station.Resident Description of Event:: Nursing staff and writer have been informed that patient had an alleged verbal altercation with her room mate (sic) who was moved into the room.[Resident 4] stated that she overheard a phone conversation of her room mate (sic) stating I will punch her and felt threatened by the comment. Prior to the comment, new room mate (sic) [Resident 3] alleged pushed her wheelchair into patients wheelchair who was sitting in bed at the time. Per [Resident 4] did not like that behavior but did not say anything.A review of the facility's policy and procedure titled Charting and Documentation revised July 2017, indicated .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record. d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident. Event ID: Facility ID: 555923 If continuation sheet Page 3 of 3