Health inspection·February 2, 2026

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1) was discharged to a facility that would be able to provide the care required by the resident. Resident 1 was discharged to an assisted living facility (ALF- a residential community providing housing, meals, and personalized support for older adults or people with disabilities who need help with daily activities [ADLsactivity of daily living] but not round the clock skilled nursing [high level medical care requiring the expertise of licensed professionals like registered nurses, licensed vocational nurses, and therapist]), which was unaware of the presence of the unstageable pressure injury ( a full thickness skin and tissue loss where the actual depth of the wound is completely obscured by slough [soft, yellowish, stringy, dead tissue] or eschar) on the right heel. This failure resulted in Resident 1 being transferred to a general acute care hospital (GACH), on the day Resident 1 was discharged from the skilled nursing facility (SNF) to the ALF, due to inability to provide the required care and services for Resident 1's pressure injury.Findings:On January 8, 2026, at 11:14 a.m., an unannounced visit to the facility on a complaint investigation was initiated.A review of Resident 1's face sheet indicated resident was admitted on [DATE], with diagnoses of pressure ulcer of right heel, unstageable; type 2 diabetes mellitus (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), wedge compression fracture of first lumbar vertebra (a common spinal injury where the front portion of the vertebral body collapses due to excessive force, while the back remains intact).A review of Resident 1's History and Physical, dated October 27, 2025, indicated resident was alert and oriented X (times) 3 (oriented to person, time, and place).On January 8, 2026, at 12:22 p.m., an interview was conducted with the SNF Case Manager (CM). The CM stated that Resident 1 was to be discharged to an ALF with home health, physical therapy, and wound care.On January 8, 2026, at ,1:49 p.m., an interview was conducted with the Treatment Nurse (TN 2). TN 2 stated that Resident 1 was admitted on [DATE], with a right heel unstageable wound, also described as a diabetic foot ulcer (DFU - an open, full-thickness wound or sore, typically located on the bottom of the foot, that occurs in individuals with diabetes). TN 2 stated that Resident 1 received daily wound cleansing with povidone-iodine (a stable chemical complex acting as a powerful, broad-spectrum topical antiseptic), and dressing changes.On January 8, 2026, at 4:45 p.m., an interview and record review was conducted with the CM. The CM confirmed that form 602 (a mandatory physician's report for seniors moving into state-licensed residential care facilities completed by a doctor to detail a resident's medical, mental, and physical capabilities, TB test results, and care needs) was completed on November 3, 2025, indicating, .Physical Health Status.m. History of Skin Condition or Breakdown was checked Yes R [right] heel w/o pressure injury was handwritten. The CM was unsure of the w/o abbreviation. The CM also confirmed (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: 555747 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 555747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Murrieta Health and Rehabilitation Center 24100 Monroe Avenue Murrieta, CA 92562 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)