Temecula Healthcare Center

Inspectors wroteBased on interview, and record review, the facility failed to complete the blood culture, (a laboratory test that checks a blood sample for disease-causing germs), for one of three residents (Resident 1), in accordance with the physician order. This failure has the potential to result in delayed treatment which could negatively affect the already fragile health of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure effective discharge planning when the facility did not provide caregiver training on the necessary care required by Resident 1 prior to discharge on [DATE]. This failure had the potential to cause anxiety to the resident and the resident's caregiver which could lead to inadequate home care and possible rehospitalization.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident or resident representative, and the Ombudsman with a new written notice of proposed transfer or discharge when a resident originally scheduled for discharge to home was instead discharged to a board and care facility. This failure had the potential to result in Resident 1 and his representative not receiving adequate notification of the change in discharge destination, nor the opportunity to appeal, potentially impacting their rights and the discharge process. Additionally, the Ombudsman not receiving the new proposed discharged notice led to a missed opportunity for the Ombudsman to advocate for the resident's safe discharge.

Inspectors wroteBased on interview and record review the facility failed to ensure an alleged incident of physical abuse involving two of seven residents reviewed (Resident 1 and Resident 2), was reported to the state survey agency (SSA) within two hours of the incident. On January 4, 2026, Resident 1 was observed pushing Resident 2, who subsequently claimed to have been choked by Resident 1. The alleged physical abuse occurred on January 4, 2026, at 6:30 p.m., and was not reported to the SSA until 9:15 a.m., on January 5, 2026. This failure had the potential for further abuse and a delay in the investigation of the event.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of seven residents (Resident 3), that the correct laboratory test was carried out and completed. The physician ordered a stool culture for C-diff (a highly sensitive, specialized laboratory test used to detect the presence of Clostridioides difficile bacteria in feces, usually in patients with persistent, antibiotic diarrhea); however the facility carried out a stool culture (a laboratory test that detects disease-causing bacteria, viruses, or fungi in a stool sample to diagnose infections causing diarrhea, fever, or abdominal pain). This failure had resulted in undiagnosed and untreated underlying cause of diarrhea leading to Resident 3 to continuously experience diarrhea until December 31, 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice for ostomy care were provided to one of three sampled residents (Resident 2), when the Licensed Vocational Nurse (LVN 1) used a wound cleanser ([NAME] Dermal Wound Cleanser) containing sorbitol (a sugar alcohol) to cleanse the peristomal skin (the area of skin around a stoma [opening] for a colostomy [a surgical procedure that creates an opening in the abdomen connecting part of the large intestine [colon] to the outside of the body, allowing stool and gas to exit through it into a collection bag). This failure caused Resident 2 to suffer pain and had the potential to irritate and damage fragile peristomal skin.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an injury of unknown origin involving one of five residents, (Resident 2) was reported to the State Survey Agency, (SSA), within two hours. Resident 2 was found by staff on April 22, 2025, visibly distressed, and verbally expressing severe pain with a bleeding wound on the right posterior scalp, which the resident could not explain the cause. This failure had the potential for a delay in the SSA investigation, which could result in missed opportunities for safety improvement and implementation of corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the discharge notice was sent to the Long-Term Care (LTC) Ombudsman at the same time the notice was provided to one of four sampled residents (Resident 1). This failure had the potential for the LTC Ombudsman not to be able to advocate for the resident in protecting their rights from inappropriate transfer and discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices when: 1. One sandwich snack was observed to be expired; 2. One dispensing scoop was left inside the container and not stored outside or on top of the mashed potato powder; 3. The kitchen door located near the garbage container area was left open for 20 minutes; and 4. Three garbage containers did not have covers. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) among a vulnerable population of 112 out of 115 residents who received food prepared in the facility's kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure, 11 of 14 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 13, 17, 19, 70, 78, 84, 90, 97, 319, 320, and 322) a copy of the AD was available and the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD. These failures had the potential to result in the ADs for Residents 13, 17, 19, 70, 78, 84, 90, 97, 319, 320, and 322 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the policy and procedures for oxygen use for two of two sampled residents (Resident 17 and 70) when: 1. Resident 70 was observed receiving continuous oxygen at an incorrect flow rate, without proper documentation or assessment; and 2. Resident 17 had an unlabeled nasal cannula (oxygen tubing - a device that delivers oxygen). These failures had the potential to result in unnecessary or unsafe oxygen administration and increased risk of infection for Residents 17 and 70.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary staff were adequately trained to carry out duties in a sanitary and safe manner when one dietary staff did not follow the manufacturer's instructions for the testing of Quaternary (Quaternary ammonium compounds [quats]are a group of chemicals used for disinfectants) sanitizer. This failure had the potential to result in inaccurate readings of the sanitizing solution, which could lead to cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs for one of three sampled residents (Resident 275), when the call light button was observed on the floor and not within reach. This failure had the potential for Resident 275 not to be able to call staff for assistance which could result in needs of the resident not being met as well as a delay in the provision of care.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents reviewed for accidents (Resident 40) was free from exposure to chemical hazards when a housekeeper (HK) left a toilet bowl cleaning solution within the resident's reach. This failure had the potential for Resident 40 to be exposed to chemical poisoning or chemical burn if the substance was ingested or mistakenly taken.

Inspectors wroteBased on interview and record review, the facility failed to effectively utilize its Quality Assessment and Performance Improvement (QAPI) program to address an ongoing issue involving missing covers on all three dumpsters. This failure resulted in the facility to not implement timely preventative measures and increased potential risk of cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a licensed nurse did not clean and disinfect a shared blood pressure (BP-pressure of blood in blood vessels) cuff according to the manufacturer's recommended contact time (the required duration the equipment must remain wet with the disinfectant to effectively kill microorganisms [germs]). This failure had the potential to expose vulnerable residents to cross-contamination and increase the risk of infections.

Inspectors wroteBased on interview and record review the facility failed to provide access to personal and medical records within two working days upon request by the resident's legal representative, for one of three sampled residents (Resident 1). This failure has the potential to delay care and treatment, affecting the resident's physical well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure for one of three sampled residents (Resident 2) had a physician order prior to hospital transfer. This failure had the potential to affect Resident 2's overall health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were accurate for one of three sampled residents (Resident 2) when the time of the alleged abused was not consistent with the time of reporting. This failure resulted in inconsistencies in the reporting timeline for Resident 2.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, and record review, the facility failed to ensure two of three residents, (Residents 4 and 5), had a discharge notice sent to the Ombudsman, (advocate for residents of nursing homes), prior to their discharges. This failure had the potential for Residents 4 and 5 to not have an advocate prior to their discharges.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents, (Resident 1), had bilateral floor mats in place as ordered. This failure had the potential for Resident 1 to have an injury due to a fall.

Inspectors wroteBased on interview and record review, the facility failed to provide copies of medical records upon request and within two business days after receiving the request from an attorney on behalf of the resident, for one of four residents reviewed, Resident 3. This failure is a violation of Resident 3 and the resident's representatives ' rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for two residents reviewed for elopement (Resident 1 and Resident 2) when Resident 1 and Resident 2 had separate elopement (incident when a resident leaves the facility without authorization or supervision necessary for safety) episodes. This failure resulted in Resident 1 and Resident 2 being able to leave the facility undetected, which could have subsequently result in accidents, injuries, or even death to the residents.

Inspectors wroteBased on document reviews, interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines/recommendations, and the facility policy, the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19) to staff and residents on 4 of 4 units. Specifically, the facility failed to conduct contact tracing (identification and monitoring of individuals who have been exposed to a disease to prevent further spread) for staff during an outbreak of COVID-19. The facility determined usage of N95 respirators (source control) negated the CDC recommendation/guidelines for testing individuals' exposure to COVID-19. Subsequently, the facility failed to test all residents and staff who had been in close contact with others who had COVID-19. [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to chicken was thawed in a safe manner for 106 of 113 sampled residents who received food from the kitchen.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to follow-up with the local authority for the completion of a Level II Preadmission Screening and Resident Review (PASARR) for 1 (Resident #93) of 2 sampled residents reviewed for PASARRs.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to submit a Level I Preadmission Screening and Resident Review (PASARR) for 1 (Resident #63) of 2 sampled residents reviewed for PASARRs.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to schedule physician ordered follow-up appointments for 2 (Resident #111 and Resident #188) of 25 sampled residents.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to have evidence to indicate a pharmacy recommendation was reviewed by the physician for 1 (Resident #10) of 5 sampled residents reviewed for medication regimen review (MRR).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call lights (device used by residents to communicate/indicate the need for assistance) were answered in a timely manner for five of seven residents (Residents 2, 3, 4, 5, 6, and 7). This failure had the potential for delayed medical management and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 13 residents consented to COVID, Influenza (flu), and/or RSV (respiratory syncytial virus - a viral infection) vaccination prior to administering the vaccine (Residents 1 through Resident 13). This failure in not ensuring residents ' rights could potentially result in negative side effects and psychosocial outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents, (Resident 3)'s call light was within reach. This failure had the potential for Resident 3 to have unmet needs, and unable to call for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable care for the protection of personal property for one of three sampled residents (Resident 1). This failure resulted in the temporary loss of Resident 1's personal property.