Temecula Healthcare Center

In the surveyor’s words

From the most serious findings on record at Temecula Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Feb 25, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Apr 17, 2025

  Based 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. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF812Feb 25, 2024

  Based 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. Findings included: Review of a facility policy titled General HACCP [Hazard Analysis and Critical Control Point] Guidelines for Food Safety, with a copyright date of 2017 revealed, 6. Safe Thawing Practices a. Thaw meat, fish and or poultry in a refrigerator in a drip proof container and in a way that prevents cross contamination. b. Completely submerge the item in clean running water that is running fast enough to agitate and float off loose ice particles. c. Thaw the item in a microwave oven using the defrost mode if it is to be cooked immediately after thawing. d. […]

• No harm, potential for more than minimal, patternF578Apr 17, 2025

  Based 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. Findings: 1. On April 14, 2025, at 3:58 p.m., an interview was conducted with Resident 70. […]

• No harm, potential for more than minimal, patternF695Apr 17, 2025

  Based 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. Findings: 1. On April 14, 2025, at 2:21 p.m., a concurrent observation and interview was conducted for Resident 70. Resident 70 was alert, oriented and able to verbalize his needs. […]