Temecula Healthcare Center

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 use of the Hoyer lift (a portable total patient lifting tool to assist in transferring patients in and out of bed) was operated with two persons for one of four residents (Resident 1). This failure placed Resident 1 at risk for falls and physical injury due to lack of adequate staff support during mechanical lift transfer. Findings:On September 9, 2025, at 2:12 p.m., observed the Physical Therapist (PT) operating the Hoyer lift to transfer Resident 1 from bed to wheelchair without a second staff member assisting. The PT roll the Hoyer lift over towards the wheelchair, with Resident 1 in the Hoyer lift. On September 9, 2025, at 2:17 p.m., during an interview with the CNA, the CNA stated that the Hoyer lift was to be used with two people to ensure resident safety. On September 9, 2025, at 2:51 p.m., during an interview with the PT, the PT stated that Resident 1 required maximum assistance for bed transfers. The PT stated that the Hoyer lift should be operated with two people, and he was operating the Hoyer lift by himself with Resident 1.Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE REDACTED], with diagnoses which included hemiplegia (paralysis of one side of the body) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity and imprecise movement).A review of Resident 1's care plan dated October 3, 2023, indicated, .ADL (activities of daily living) Self-Care Performance Deficit .Interventions .Provide appropriate self-performance and support needed during ADL care .A review of Resident 1's Functional Abilities and Goals, dated August 8, 2025, indicated .Mobility .Chair/bed-to-chair transfer .substantial/maximal assistance [resident does 25-49% of the effort] .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. 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require b. Transferring a resident from bed to chair.

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

Event ID:

Printed: 04/13/2026 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

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:

If continuation sheet