Health inspection·December 31, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings:On December 10, 2025, at 10:07 a.m., an unannounced visit to the facility on a complaint and Facility Reported Incident were initiated. A review of Resident 2's medical records indicated the resident was admitted on [DATE], with diagnoses of encounter for surgical aftercare following surgery on the digestive system, pneumonitis (infection) due to inhalation of food and vomit, pressure ulcer, (bed sore) of sacral region, (lies between the fifth segment of the lower spine and the tailbone), 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), encounter for encounter for attention to colostomy.On December 10, 2025, at 11:59 a.m., an interview was conducted with the Licensed Vocational Nurse (LVN 1). LVN 1 stated he was working on December 10, 2025, and provided care to Resident 2. LVN 1 stated that he changed Resident 2's colostomy bag, cleansed the area with warm water and gauze, and applied a new colostomy bag at approximately 8 p.m. LVN 1 further stated that after returning from a break, a Certified Nursing Assistant (CNA) informed him that Resident 2's colostomy bag was leaking. LVN 1 stated that upon assessment, he observed some redness, where the adhesive contacted the skin, used a wound cleanser to clean the skin and applied a new colostomy bag. On December 10, 2025, at 12:19 p.m., during an interview with the Registered Nurse (RN), the RN stated that on December 6, 2025, she received a call from the Assistant Director of Nursing (ADON) to check on Resident 2. The RN stated that Resident 2 reported that during the colostomy bag change on December 5, 2025, LVN 1 sprayed a liquid on the site that caused severe pain that he had to cover his mouth to avoid screaming out in pain. The RN stated that she reported the incident to the facility administrator. On December 10, 2025, at 12:26 p.m., an interview was conducted with Resident 2. Resident 2 stated on December 5, 2025, at approximately 8:25 p.m., the colostomy bag was leaking and needed to be changed. Resident 2 stated that on December 5, 2025, approximately 9:20 p.m., LVN 1 removed the leaking colostomy bag and used a spray that smelled very strong and burned so badly he had to bite down on his knuckles to keep from screaming. Resident 2 stated that the spray felt like alcohol. Resident 2 stated that on Saturday, December 6, 2025, he reported the incident to ADON by telephone. On December 10, 2025, at 1:30 p.m., an interview was conducted with the Director of Nursing, Residents Affected - Few Page 1 of 2 555923 555923 12/31/2025 Temecula Healthcare Center 44280 Campanula Way Temecula, CA 92592

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (DON). The DON stated that Resident 2's physician orders indicated to change the colostomy bag as needed when 3/4 full. The DON stated that usually they would cleanse the peristomal area with normal saline. On December 10, 2025, at 1:48 p.m., during an interview with the Treatment Nurse, the TN stated that Resident 2 had a colostomy bag and would require colostomy bag changes as needed. The TN stated that the peristomal skin would be cleansed with gauze soaked with normal saline. The TN stated that wound cleanser would not be used on the peristomal skin, as it would cause burning. On December 10, 2025, at 2:31 p.m., during an interview with LVN 1, LVN 1 confirmed that [NAME] Dermal Wound Cleanser was used on Resident 2's peristomal skin on December 5, 2025. A review of the listed ingredients indicated sorbitol was the second ingredient listed. A review of Resident 2's Summary Order Report dated November 13, 2025, indicated .Change colostomy bag PRN [as needed] if soiled or dislodgement. Cleanse stoma area & dry gently. Apply ointment as ordered.A review of Resident 2's Health Status Note dated December 5, 2025, at 10:25 p.m., indicated Patient noted with leaking colostomy appliance during PM shift. Colostomy bag was changed twice at 20:00 and 21:50 due to leaking brown BM. Stoma assessed during each change; stoma pink, moist, and intact. Peristomal skin cleansed with warm water, dried thoroughly, and new appliance applied with proper seal. No redness or skin breakdown noted.A review of Resident 2's eINTERACT SBAR Summary for Providers dated December 6, 2025, at 12:54 p.m., indicated .Pt reported an alleged physical abuse against a staff member. Pt explained that it happened while charge nurse was changing his colostomy bag and cleaning his surgical site. Pt reported that a liquid was sprayed that felt like alcohol to his open wound. Pt stated that the pain caused by the spray was unbearable and he had to cover mouth from screaming. Patient further stated the work had to be re-done during the next shift.A review of the Wound, Ostomy, and Continence Nurses Society guidelines titled Basic Ostomy Skin Care published July 2024, indicated .Cleaning the Skin Around the Ostomy. Clean the skin around the ostomy with warm water and a washcloth or soft paper towel and pat dry. Do not use alcohol or any other harsh chemicals to clean the skin around the ostomy. They can cause the skin to get sore. 555923 Page 2 of 2