Temecula Healthcare Center: Wound Cleanser Burn Complaint - CA
The incident happened at Temecula Healthcare Center on December 5, 2025. By the next afternoon, the resident had reported it as an allegation of physical abuse.
The resident, identified in inspection records only as Resident 2, had a colostomy, a surgical opening in the abdomen through which waste exits the body into an attached bag. The skin immediately surrounding that opening, called peristomal skin, is among the most sensitive tissue a nurse will ever handle. It is raw, often irritated, and in direct contact with bodily waste. The standard guidance from the Wound, Ostomy, and Continence Nurses Society, published in July 2024, is unambiguous: clean the area with warm water and a soft cloth, and do not use alcohol or harsh chemicals. They cause the skin to get sore.
What Resident 2 says happened on the evening of December 5 was something different.
According to a facility document called an eINTERACT SBAR Summary, completed the following day at 12:54 p.m., the resident reported that while a charge nurse was changing his colostomy bag and cleaning his surgical site, a liquid was sprayed that felt like alcohol onto his open wound. He described the pain as unbearable. He said he had to cover his mouth to keep from screaming. He also said the work had to be redone during the next shift.
The resident called it abuse.
The facility's own nursing notes from that same evening told a different story. A Health Status Note dated December 5 at 10:25 p.m. documented that the colostomy bag had leaked during the PM shift and was changed twice, once at 8 p.m. and again at 9:50 p.m. The note said the stoma was assessed during each change and appeared pink, moist, and intact. It said the peristomal skin was cleansed with warm water, dried thoroughly, and that no redness or skin breakdown was noted.
The note made no mention of a wound cleanser. It made no mention of a resident in pain. It made no mention of anyone covering their mouth to keep from screaming.
What federal inspectors found, when they reviewed the record and interviewed staff, was that a product called Dermal Wound Cleanser had in fact been used on Resident 2's peristomal skin that day. A licensed vocational nurse identified in the report as LVN 1 confirmed it during an interview on December 10, 2025, at 2:31 p.m. The wound cleanser had been used on December 5. The nurse confirmed it directly.
A review of the cleanser's ingredient list showed sorbitol listed as the second ingredient. A separate interview with a treatment nurse, identified as TN, established that the facility's own protocol called for peristomal skin to be cleansed with gauze soaked in normal saline. The treatment nurse said the wound cleanser would not be used on peristomal skin because it would cause burning.
The facility's own protocol. The facility's own nurse. Burning.
Resident 2's Summary Order Report, dated November 13, 2025, had specified the care plainly: change the colostomy bag as needed if soiled or dislodged, cleanse the stoma area and dry gently, apply ointment as ordered. There was nothing in those orders about a wound cleanser. There was nothing in the professional guidelines about anything other than warm water and a soft cloth.
What makes this harder to read is the gap between the nursing note and what the resident described. The note, written the same night, said warm water was used, said there was no redness, said the stoma was intact. The resident, the next day, described pain that made him want to scream. He described a liquid that felt like alcohol on an open wound. He described the work having to be done over.
Those two accounts cannot both be complete.
Inspectors classified the violation at a level of minimal harm or potential for actual harm, and noted that few residents were affected. The complaint inspection was completed December 31, 2025.
What the record does not resolve is what Resident 2 experienced in the hours between the first bag change at 8 p.m. and the second at 9:50 p.m., or what he experienced through the rest of that night, lying in a facility bed with peristomal skin that his own nurses acknowledged could burn when exposed to the wrong product. The nursing note said no redness or breakdown was noted. The resident said the pain was unbearable.
He said he had to cover his mouth.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Temecula Healthcare Center from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
TEMECULA HEALTHCARE CENTER in TEMECULA, CA was cited for violations during a health inspection on December 31, 2025.
The incident happened at Temecula Healthcare Center on December 5, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.