Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ramona Rehabilitation And Post Acute Care Center during CMS and state inspections, most recent first.
Food prep and storage practices were not followed when a convection oven was observed with solidified greasy residue and black crusted buildup, despite the DS stating it was cleaned weekly. An opened package of white loaf bread was also found on the shelf without an open date or use-by date, even though the DS and RD stated opened foods were expected to be labeled and dated per facility policy.
A resident with CHF and a recent blood clot had bilateral leg edema and reported worsening swelling and calf pain, but nursing documentation did not consistently show ongoing edema monitoring as ordered. Another resident with sepsis and edema of all extremities had undocumented low BP readings and no documented physician notification. A third resident became lethargic and difficult to arouse, yet the change in LOC was not reported to the MD. A fourth resident developed left elbow skin discoloration from bumping the side rail, but staff did not identify, assess, document, or notify the MD about the new skin change.
Medication administration errors and inaccurate eMAR documentation resulted in an 11.9% error rate during med pass observations for two residents. An LPN gave an incorrect vitamin supplement instead of ordered vitamin B12 for one resident, and for another resident administered the wrong aspirin dosage form while documenting calcium carbonate and GlycoLax as given even though they were not administered. The DON stated staff are required to follow the rights of medication administration, verify labels against the MAR during three checks, and document medications accurately.
Improper medication storage and labeling were found in multiple medication carts. An insulin pen for a resident with diabetes was kept at room temperature without a documented refrigeration removal date, two discontinued controlled medications remained mixed with active meds in a cart, and a levalbuterol vial was stored outside its foil pouch without a label or removal date. The LVNs and DON confirmed the storage conditions did not match policy or manufacturer instructions.
Infection control practices were not followed when an LVN used the same BP cuff and stethoscope on two residents without cleaning or disinfecting the shared equipment before or after use. A CNA also failed to perform hand hygiene while serving meal trays to multiple residents, including residents in EBP rooms. In addition, a CNA did not wash hands with soap and water before and after entering the room of a resident on contact isolation for C. difficile, despite the resident’s positive stool culture and isolation status.
Failure to document rationale for ongoing PRN lorazepam use: A resident with anxiety, Alzheimer's disease, depression, psychosis, and insomnia received repeated PRN lorazepam doses over several months, with orders renewed multiple times and one order limited to 14 days but continued beyond that period. The IDT review noted the medication was effective and continued, but the record lacked physician-documented clinical rationale or a specified duration supporting use beyond 14 days, and the DON confirmed the hospice note and progress notes did not contain that documentation.
Failure to Document PRN Pain Medication Administration: An LVN administered PRN acetaminophen to a resident with recent abdominal surgery and mild pain, but did not document the dose in the MAR at the time it was given. The MAR lacked the nurse's initials, time of administration, and effectiveness documentation, and the DON confirmed the omission was not in accordance with facility policy.
A facility failed to timely review and act on consultant pharmacist MRR recommendations for two residents receiving omeprazole. One resident’s recommendation was incomplete and unreadable, with no documentation that it was clarified, endorsed to the MD, or reviewed by the MD; the other resident’s recommendation to change the omeprazole administration time remained unaddressed, and the MAR continued to show the original 9 a.m. schedule. The DON confirmed there was no documented physician action and stated review should occur within three to seven days.
A resident on a CCHO renal diet with ESRD and diabetes received a lunch tray that included barbeque sauce, even though the diet spreadsheet and menu specified no BBQ sauce for renal diets. The DS identified the error during tray line observation, and the RD confirmed that kitchen staff did not follow the spreadsheet for the resident's diet.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with a history of sepsis and bacteremia did not receive IV antibiotics as ordered following hospital discharge, with multiple missed doses of ampicillin and ceftriaxone documented. Facility staff were unclear about the correct duration and continuity of the antibiotic orders, resulting in interruptions and delayed restarts of medication. This failure led to the need to extend the IV antibiotic course to address the resident's infection.
A facility failed to report an abuse allegation involving a CNA and a resident to CDPH within the required two-hour timeframe. The incident involved a resident with mild cognitive impairment, who was heard screaming about being hit and choked. Despite the lack of visible injuries, the facility's policy required immediate reporting, which was not followed, potentially delaying the investigation and exposing residents to further abuse.
Three residents were found with medications at their bedside without proper assessments or physician orders for self-administration. A resident had Nystatin powder, another had Desitin ointment, and a third had eyedrops, all without documented assessments or orders. The ADON confirmed that policies were not followed, posing potential risks to residents.
The facility failed to remove expired, discontinued, and unlabeled medications from medication carts and storage rooms, as observed during inspections. Expired medications, including ondansetron, clonidine, and dicyclomine, were found in medication carts, while an unlabeled IV bag and an expired Tubersol vial were found in storage rooms. Nurses acknowledged the oversight, and the facility's policies for removing expired medications were not followed.
The facility failed to follow safe food storage practices, as observed during a survey. A can of cranberry jelly was undated, celery was exposed to air in the refrigerator, and spinach bars in the freezer were not dated. The Dietary Manager confirmed that all food items should be dated and sealed.
The facility failed to implement proper infection control practices, including a CNA not using PPE for a resident requiring enhanced precautions, improper handling of clean linens by laundry staff, a COTA neglecting hand hygiene, failure to change nebulizer tubing as scheduled, and direct care staff wearing long artificial nails, all of which increased the risk of infection spread among residents.
A resident with obstructive uropathy and a Foley catheter was observed with an uncovered urinary bag, contrary to the facility's dignity policy. An LVN acknowledged the oversight, and the ADON confirmed the potential psychosocial impact. Facility policies emphasize maintaining resident dignity by covering urinary bags.
A resident with significant medical conditions experienced delays in receiving assistance, as call lights were not answered promptly by staff. Despite the facility's policy requiring prompt response, staff were observed ignoring the call light, leading to potential unmet needs for the resident.
A resident with severe pain did not receive the prescribed Norco 10-325 mg due to unavailability and was instead given Norco 7.5-325 mg, intended for moderate pain. Despite reporting severe pain, the facility failed to manage the resident's pain effectively, as confirmed by medication records and staff interviews.
A resident on apixaban for deep vein thrombosis was found with multiple bruises, but the facility failed to monitor for adverse effects of anticoagulant use. Staff interviews revealed a lack of awareness and action, and the facility's policy on monitoring anticoagulant therapy was not followed.
A facility failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with multiple medical conditions, including chronic wounds. The Treatment Nurse did not wear a gown as required by the EBP protocol, despite the presence of a sign indicating EBP on the resident's room. This oversight was observed during an unannounced complaint investigation.
A resident's call light was found on the floor, out of reach, during an unannounced visit. The CNA confirmed the call light should be within reach, as per facility policy. The resident, with multiple health issues and cognitive impairments, had a care plan emphasizing the need for accessible call lights.
A Treatment Nurse in an LTC facility failed to perform hand hygiene between glove changes while providing wound care to a resident, potentially contaminating the resident's wounds. The resident had a history of cellulitis, lumbar fracture, and COPD. The facility's policy and CDC guidelines require hand hygiene before and after glove use, which was not followed in this instance.
A resident with cognitive impairment and depression alleged sexual abuse by a CNA, who was not immediately removed from duty, causing the resident distress. The incident was reported two hours later, contrary to facility policy requiring immediate action.
The facility failed to follow physician orders for a resident with multiple diagnoses, including hypertension and atrial fibrillation. Medications were not administered according to specified parameters, and staff did not document reasons for holding medications. Interviews with the LVN and DON confirmed these deficiencies.
Food Storage and Equipment Cleaning Deficiencies
Penalty
Summary
Safe and sanitary food preparation and storage practices were not followed in the kitchen. During an initial tour with the Dietary Supervisor, the convection oven was observed with solidified greasy residue on the glass doors and black crusted residue at the bottom of the oven. In interview, the Dietary Supervisor stated the convection oven was cleaned once a week with a degreaser. The Registered Dietician later stated the expectation was for kitchen staff to follow the cleaning schedule and keep kitchen equipment clean and in sanitary condition. The facility policy titled RANGES AND OVENS stated ovens were to be cleaned weekly and as often as necessary, and the FDA Food Code stated nonfood-contact surfaces of equipment shall be kept free of accumulation of food residue and cleaned at a frequency necessary to preclude accumulation of soil residues. An opened package of white loaf bread was also found stored on the shelf and readily available for use with a date of January 30, 2026, but without an open date or use-by date. The Dietary Supervisor stated the opened bread did not have an open date and use-by date and that bread is good for seven days after opening. The Dietary Supervisor also stated kitchen staff should place a label with an open date and use-by date for food that was already open. The Registered Dietician stated kitchen staff were expected to label all opened foods with an open date and a use-by date. The facility document titled DRY GOODS STORAGE GUIDELINES stated bread shelf life when opened is between five to seven days, and the facility policy titled LABELING AND DATING FOODS stated all food items in storage need to be labeled and dated and newly opened food items need to be closed and labeled with an open date and used-by date.
Failure to Monitor Edema, Blood Pressure, Mental Status, and Skin Changes
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring of a resident with bilateral lower extremity edema and a history of CHF and a right lower extremity blood clot. The resident was observed with edema in both lower extremities, reported worsening left leg edema and new pain behind the right knee/calf, and stated nursing staff checked the edema only occasionally. The record showed physician orders to monitor both lower extremities for worsening edema every shift for 14 days, but daily skilled charting did not document the status of the edema on multiple dates during that period. The ADON stated the edema should have been monitored daily and that nursing staff were expected to follow the care plan and physician orders. The facility also failed to provide ongoing assessment and monitoring for a resident with edema of both upper and lower extremities and low blood pressure. The resident was admitted with severe sepsis and septic shock, and the admission screening documented bilateral arm and leg edema. Daily skilled charting did not document the status of the edema on several dates after admission, and later charting described very deep pitting edema in both upper and lower extremities. The record also showed blood pressure readings of 75/54 mmHg and 72/51 mmHg, but there was no documented evidence that the low blood pressure readings were addressed or that the physician was notified. The ADON stated the low blood pressure was too low and should have been reported, and that edema assessment was part of the nursing head-to-toe assessment. The facility failed to notify the physician of a resident's change in level of consciousness. The resident had diagnoses including cognitive functions following cerebral infarction, and the admission screening indicated the resident was not comatose. The resident was observed sleeping, difficult to arouse, not awakening to voice, and unable to answer simple questions during speech therapy. The speech therapist stated the resident had been sleepy for the last couple of days and was unable to tolerate thin liquids. CNA staff stated the resident's baseline was alert and that the resident had been lethargic and confused, and the LVN stated a change in mental status or lethargy should be reported to the physician. The ADON stated the resident's baseline was alert and that any change in condition from baseline was expected to be assessed, monitored, documented, and reported to the physician. The facility also failed to identify, assess, monitor, and notify the physician about a resident's left elbow skin discoloration. The resident was observed with purplish discoloration on the left elbow and stated the area occurred from repeatedly bumping the arm on the side rail. Later, the discoloration was still present but fading. Staff interviews indicated a new skin condition should be assessed, monitored, documented, and reported to the physician, but there was no documented evidence that the left elbow discoloration was identified, assessed, monitored, or reported. The resident had diagnoses including hemiplegia and hemiparesis, and the MDS indicated the resident was cognitively intact and had no skin conditions.
Medication administration errors and inaccurate documentation
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and its medication administration policies, resulting in a medication error rate of 11.9% with five errors out of 42 medication administration opportunities during observations for two residents. The errors included administration of an incorrect medication, administration of an incorrect dosage form, and omission of ordered medications while documenting them as given. For one resident, an LVN administered vitamin C 500 mg during the observed medication pass even though there was no physician order for vitamin C. The resident did have an order for cyanocobalamin (vitamin B12) 500 mcg daily, but that ordered medication was not administered during the observation. The MAR showed vitamin C was not documented as given, while cyanocobalamin 500 mcg was documented as administered at 9 a.m. The LVN later confirmed the error and stated the mistake may have occurred because the bottles were similar in size and appearance and both began with Vitamin and contained 500 in the strength. For another resident, an LVN administered aspirin 81 mg enteric-coated tablet instead of the ordered aspirin 81 mg chewable tablet. The same resident’s calcium carbonate 500 mg and GlycoLax were documented as administered at the 9 a.m. medication pass, but the LVN confirmed they were not actually given. The LVN stated there were no medication bottles for aspirin chewable, calcium carbonate, or GlycoLax in the medication cart at the time, that GlycoLax had been discarded earlier that morning and not replaced before the pass, and that she may have selected yes in the eMAR without verifying each medication before documentation. The DON stated staff are required to follow the rights of medication administration, verify labels against the MAR during three preparation checks, and accurately document medications administered.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure medications were stored according to policy and manufacturer instructions when an insulin pen for a resident with diabetes was found in the medication cart at Nursing Station 3 without documentation of the date it had been removed from refrigeration. The HumaLOG KwikPen was stored at room temperature in an opened manufacturer’s box, and the LVN who inspected it stated she did not know when it had been taken out of the refrigerator. The DON later reviewed the manufacturer insert and acknowledged that, without the removal date, the 28-day room-temperature stability period could not be determined and the pen should have been discarded. The facility also stored discontinued controlled substances in the medication cart with active medications at Nursing Station 4. A blister card of Ambien 5 mg for one resident and a blister card of Tramadol 50 mg for another resident were both found in the cart even though the physician orders showed both medications had been discontinued weeks earlier. The LVN confirmed the medications were discontinued and remained in the cart, and stated discontinued medications should be marked discontinued, removed from the cart, and given to the DON for proper disposal if controlled substances. The DON acknowledged the medications should have been removed and secured separately pending destruction. In addition, a unit-dose vial of levalbuterol inhalation solution was found in the top drawer of the split nursing station medication cart outside its protective foil pouch, without a prescription label, and without documentation of when it had been removed from the pouch. The LVN confirmed it lacked labeling and light protection and stated it should have been removed and discarded. The DON later reviewed the manufacturer insert and acknowledged the vial should have been discarded because it was unlabeled, not protected from light, and lacked a documented removal date from the foil pouch.
Infection Control Failures With Shared Equipment, Hand Hygiene, and C. difficile Isolation
Penalty
Summary
Proper infection prevention and control practices were not followed for shared medical equipment used on two residents. During medication administration observations, an LVN retrieved the same BP cuff from the bottom drawer of her medication cart and entered the rooms of two residents with a stethoscope draped around her neck. The BP cuff and stethoscope were used to obtain blood pressure readings for both residents without being cleaned or disinfected before use, and after each use the equipment was placed back on the cart or kept around the LVN’s neck without disinfection. The LVN later acknowledged the equipment was shared and should have been cleaned and disinfected with germicidal wipes between residents. The DON stated the BP cuff and stethoscopes were shared medical equipment and required cleaning and disinfection before and after each use. Hand hygiene was not performed by a CNA while serving meal trays to four residents in Station 2 during lunch service. The CNA was observed delivering trays to residents, including residents in rooms under Enhanced Barrier Precaution, while handling tray items with bare hands and moving between rooms without performing hand hygiene. The CNA confirmed she did not clean her hands in between serving the trays and stated staff should perform hand hygiene between residents. The IP stated passing trays was part of patient care and that staff should wash hands or use ABHR between residents, and the facility policy required hand hygiene before and after assisting a resident with meals. Handwashing was also not performed by a CNA when entering and re-entering the room of a resident on contact isolation for C. difficile. The resident had a positive stool culture for C. difficile toxins and was on contact isolation precautions. The CNA donned PPE and entered the room, then removed PPE and used hand sanitizer after leaving. She later retrieved a diaper from the linen cart, donned PPE again, and re-entered the room without washing her hands with soap and water. The CNA stated she used hand sanitizer when leaving the room but did not wash her hands before re-entering. The IP stated staff were expected to wash hands with soap and water before entering and after leaving the room of a resident on C. difficile isolation, and the facility policy stated soap and water is superior to ABHR for removing C. difficile spores.
Failure to Document Rationale for Ongoing PRN Lorazepam Use
Penalty
Summary
The facility failed to ensure the physician evaluated and documented the clinical rationale supporting continued use of PRN lorazepam beyond 14 days for one resident. The resident was admitted with diagnoses including anxiety disorder, Alzheimer's disease, major depressive disorder, psychosis, and insomnia, and the care plan identified the resident as being at risk for adverse side effects and mood concerns related to antianxiety medication use. The care plan also noted episodes of crying when confused and anxious. The resident had multiple PRN lorazepam orders over the course of the review period, beginning with an order for lorazepam 0.5 mg every 6 hours as needed for anxiety/restlessness/agitation and later renewed several times at the same dose and frequency, with the indication changed to anxiety manifested by crying out and later restlessness. One order on December 17, 2025, was written with a specified duration of 14 days, but the medication remained active beyond that period. The MAR showed repeated administration across multiple months, including 19 doses in March, 14 in April, 4 in May, 3 in July, 13 in August, 26 in September, 41 in October, 34 in November, 21 in December, 9 in January, and 5 through February 13, 2026. The record included a psychotropic IDT review noting the PRN lorazepam was effective and that the frequency of administration had no change, with a recommendation to continue the current regimen. However, the record did not include physician-documented clinical rationale or a specified duration supporting continuation of the PRN lorazepam beyond 14 days. Progress notes reviewed for several dates also did not document a clinical rationale or duration for continued PRN use, and the DON confirmed the hospice note did not include the required physician rationale. The facility policy stated that when a PRN psychotropic reaches 14 days, the prescribing practitioner determines whether continuation is clinically indicated and documentation shall reflect clinical rationale and ongoing need when available.
Failure to Document PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure medications were administered and documented according to physician orders and facility policy when nursing staff gave a PRN dose of acetaminophen but did not record it in the Medication Administration Record (MAR). During observation of Resident 108, the LVN asked about pain, discussed Tylenol with the resident, and then administered two tablets of acetaminophen 325 mg for mild pain. Resident 108 had been admitted with diagnoses including small bowel obstruction and hernia status post exploratory laparotomy, and the physician order dated February 8, 2026, directed Tylenol 325 mg, two tablets by mouth every six hours as needed for mild pain. A later review of the MAR showed no documentation of the 9 a.m. PRN acetaminophen dose, including no initials, time of administration, or documentation of effectiveness. During interview, the LVN confirmed the medication had been given but not documented in the electronic MAR and stated she forgot to select Yes in PCC. The DON stated medication administration must be documented immediately after administration and confirmed the PRN acetaminophen was not documented until the omission was brought to the facility's attention, which was not in accordance with facility policy.
Delayed Review of Consultant Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure the consultant pharmacist’s monthly medication regimen review recommendations were reviewed and acted upon in a timely manner for two residents. Resident 28 had an active order for omeprazole 20 mg daily for acid indigestion, and the consultant pharmacist’s December 2025 MRR included a recommendation related to omeprazole; however, the recommendation was incomplete, partially unreadable, and missing portions, so the full content could not be determined. There was no documented evidence that the facility clarified the recommendation with the consultant pharmacist, endorsed it to the physician, or documented physician review, acceptance, or rejection of the recommendation. The DON confirmed the recommendation remained incomplete and stated she should have clarified it and endorsed it to the physician, and that physician review of consultant pharmacist recommendations should occur within three to seven days. Resident 79 had an order for omeprazole 20 mg each morning for GI prophylaxis, and the consultant pharmacist’s December 2025 MRR recommended changing the administration time from 9 a.m. to 6:30 a.m. so it could be given on an empty stomach before breakfast. The MAR showed omeprazole continued to be scheduled and administered at 9 a.m. from November 2025 through February 2026, except for one held dose, and there was no documentation on the MRR, in physician progress notes, or elsewhere showing physician review, response, acceptance, or rejection of the recommendation. The DON confirmed the recommendation was not reviewed by the physician in a timely manner and acknowledged there was no documented physician action regarding it.
Renal Diet Tray Included Prohibited Barbeque Sauce
Penalty
Summary
The facility failed to ensure that food served met individual dietary needs for one resident on a renal diet. During a tray line observation on February 11, 2026, the meal tray prepared for Resident 109 included barbeque pork, barbeque sauce, a bread roll, brussels sprouts, and polenta. When the Dietary Supervisor inspected the tray, the supervisor stated that Resident 109 was on a renal diet and should not have received barbeque sauce. Resident 109 was admitted with end stage renal disease and diabetes. The physician order dated February 4, 2026, specified a CCHO renal diet with regular texture and regular consistency. The facility’s winter menu for February 11, 2026, listed renal diets as pork with gravy and specifically noted no BBQ sauce. During an interview on February 12, 2026, the Registered Dietician stated kitchen staff should follow the spreadsheet when serving foods to residents and confirmed that Resident 109 could not have barbeque sauce in the diet.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of sepsis, bacteremia, and a xenogenic heart valve did not receive intravenous (IV) antibiotic medications as ordered by the physician upon discharge from a general acute hospital. The resident was admitted with orders to continue prolonged IV ampicillin and ceftriaxone for a specified duration, with clear instructions documented in the admission and transfer summaries, as well as in the physician's progress notes. However, a review of the Medication Administration Record (MAR) revealed multiple missed doses of both antibiotics over several dates, including a significant gap in ampicillin administration from mid-December to late December, and several missed doses of ceftriaxone. The facility's care plans for the resident included interventions to administer IV therapy and antibiotics as ordered, and the facility's policy required licensed nurses to verify orders and document all administration details. Despite these protocols, interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) indicated confusion and lack of clarity regarding the duration and continuity of the antibiotic orders. The ADON noted that a registry night shift RN changed the ampicillin order from 34 days to 4 days without clear justification, and there was no explanation for the interruption and delayed restart of the medication. The DON also expressed uncertainty about why the ampicillin was stopped and restarted multiple times, stating it should have been administered consistently as originally ordered. The resident's progress notes and discharge summary confirmed that the IV ampicillin course was cut short prematurely and had to be restarted to complete the intended duration. The failure to administer the IV antibiotics as prescribed resulted in the need to extend the IV medication period to address the resident's infection. Documentation and interviews confirmed that the facility did not follow physician orders or its own policies for safe and effective administration of IV antibiotics, leading to the identified deficiency.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a Certified Nursing Assistant (CNA) and a resident to the California Department of Public Health (CDPH) within the required timeframe. The incident occurred on October 28, 2024, when the Assistant Director of Nursing (ADON) informed the Administrator (ADM) about the alleged abuse at 1:00 p.m. However, the ADM did not report the incident to CDPH until October 31, 2024, which was beyond the mandated two-hour window for reporting such allegations. This delay in reporting had the potential to hinder the timely investigation of the abuse claim and possibly expose other residents to further abuse. The incident involved a resident with a history of pulmonary fibrosis, chronic respiratory failure, and anxiety, who was admitted to the facility with a mild cognitive impairment. On the day of the incident, another CNA observed the accused CNA leaving the resident's room with food and fluid on her clothes, while the resident was heard screaming about being hit and choked. Despite the lack of visible injuries on the resident, the facility's policy required immediate reporting of any abuse allegations, which was not adhered to in this case.
Failure to Conduct Self-Administration Assessments for Medications
Penalty
Summary
The facility failed to conduct assessments for the safe self-administration of medications for three residents. Resident 20 was found with a 30 ml cup of Nystatin External Powder on her bedside table, which she stated was left by a nurse for her to apply later. Despite having a BIMS score indicating cognitive intactness, there was no documented assessment for her ability to self-administer the medication, nor was there a physician's order permitting her to do so. Licensed Vocational Nurse (LVN) 2 confirmed that the medication should not have been left at the bedside without an assessment. Resident 30 had an opened tube of Desitin ointment on his bedside table, which he used to relieve a rash. His medical records showed no evidence of a self-administration assessment or a physician's order for the ointment. LVN 2 acknowledged that the medication should not have been kept at the bedside and that a self-administration assessment was necessary. Similarly, Resident 33 was found with an opened bottle of eyedrops on her overbed table, which she used for eye irritation. Her records also lacked a self-administration assessment and a physician's order for the eyedrops. The Assistant Director of Nursing (ADON) stated that licensed nurses are expected to follow the facility's policy and procedure regarding self-administration assessments and medication administration. The facility's policy requires that any medications found at the bedside without authorization for self-administration be turned over to the nurse in charge. The failure to adhere to these policies resulted in the potential for residents to receive medications without proper monitoring, which could lead to harmful effects.
Expired and Unlabeled Medications Found in Facility
Penalty
Summary
The facility failed to ensure that expired, discontinued, and unlabeled medications and intravenous (IV) fluids were not readily available for use, as observed during inspections of medication carts and storage rooms. On October 23, 2024, an inspection of the Station 4 Medication Cart revealed several expired medications, including ondansetron, clonidine, hyoscyamine, and chest congestion tablets, which were still stored in the cart. Licensed Vocational Nurse (LVN) 9 acknowledged that these medications were expired and should have been removed to prevent potential harm to residents. Similarly, an inspection of the Station 3 Medication Cart found expired dicyclomine and ondansetron tablets, which LVN 10 confirmed were discontinued and should have been removed. Further inspections on October 24, 2024, revealed additional deficiencies in medication storage practices. In the Station 1 Medication Storage Room, a bag of Dextrose 10% IV was found unlabeled and readily available for use, which Registered Nurse (RN) 1 confirmed should have been labeled. In the Station 2 Medication Storage Room, a multi-dose vial of Tubersol injection was found stored beyond its expiration date, which RN 1 acknowledged should have been disposed of after 30 days of opening. The facility's policies and procedures, including those for auditing and removing expired medications, were not adhered to, as evidenced by the presence of expired and unlabeled medications in the medication carts and storage rooms. The Assistant Director of Nursing (ADON) stated that it was the nurses' responsibility to ensure expired medications were removed from the carts, and the facility's policy indicated that expired medications should be removed regularly and when encountered. However, these protocols were not followed, leading to the deficiencies observed during the survey.
Improper Food Storage Practices
Penalty
Summary
The facility failed to adhere to safe food storage practices in the kitchen, as observed during a survey. A seven-pound can of cranberry jelly was found in the dry storage area without a date, indicating a lack of proper labeling. Additionally, two stalks of celery were discovered in the walk-in refrigerator with the plastic bag open, exposing the celery to air, which is against the facility's policy of keeping food items sealed. Furthermore, five three-pound bars of chopped spinach were found in the freezer without any dates, violating the facility's policy that requires all food items to be dated when received. These lapses in food storage practices were identified during an initial kitchen tour with the Dietary Manager, who acknowledged that all food items should be dated and properly sealed to prevent exposure to air.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances, leading to potential risks of infection spread among residents. A Certified Nursing Assistant (CNA) did not use personal protective equipment (PPE) when providing care to a resident who required enhanced barrier precautions due to an indwelling catheter and other medical conditions. Despite clear signage and instructions, the CNA admitted to forgetting to wear the necessary gown and gloves, which was confirmed by interviews with other staff members, including the Infection Prevention (IP) nurse and the Assistant Director of Nursing (ADON). In another instance, the Laundry Staff (LS) did not follow proper procedures for handling and storing clean linens. The LS was observed stacking linens in a cart without a protective gown and allowing them to come into contact with a wall, which was considered a contaminated surface. This improper handling was acknowledged by the LS and confirmed by the Housekeeping/Laundry Supervisor and the IP, who emphasized the risk of cross-contamination and infection spread due to such practices. Additionally, a Certified Occupational Therapy Assistant (COTA) failed to perform hand hygiene before and after providing therapy to residents, which was observed and admitted by the COTA. The Director of Rehab and the IP highlighted the importance of handwashing to prevent infection spread. Furthermore, the facility staff did not adhere to the schedule for changing nebulizer tubing, as observed with Resident 50, whose tubing showed signs of buildup and was not changed as per the physician's order. Lastly, two direct care staff members were found wearing long artificial nails, contrary to the facility's policy, which could harbor pathogens and pose a risk of infection to residents.
Failure to Cover Urinary Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident by not covering their urinary bag, which was observed hanging below the level of the resident's bed and filled with 300 ml of yellow liquid. This incident was noted during an observation with an LVN, who acknowledged that the urinary bag should have been covered with a dignity bag to prevent embarrassment. The resident, who was admitted with obstructive uropathy and had a Foley catheter in place, lacked the capacity to understand and make decisions, as indicated in their medical records. The facility's policy on dignity, dated February 2021, mandates that residents are treated with dignity and respect at all times, including keeping urinary catheter bags covered. The Assistant Director of Nursing confirmed that leaving the urinary bag uncovered could have a psychosocial effect on the resident and that it should have been covered. The facility's policy on Resident Rights also emphasizes the importance of maintaining or enhancing each resident's dignity and respect.
Failure to Respond to Call Light Promptly
Penalty
Summary
The facility failed to answer the call light within a reasonable time for one resident, which had the potential to not meet the resident's needs. An interview with the resident revealed that he could not get help for up to an hour, usually during the morning shift. The resident was admitted with a fusion of the spine, wedge compression fracture of T7-T8 vertebrae, and ankylosing spondylitis of the thoracic region, and was mentally capable of understanding. The family representative confirmed that the resident complained about the lack of response from the nursing staff, stating that assistance was only provided when she called the nurse's station from home. Observations on a specific date showed the call light in the resident's room was on while several staff members were talking at the nurse station, and a CNA was seen walking from room to room without answering the call light. The CNA acknowledged that call lights should be answered promptly and admitted to hearing the call light but not responding. The facility's policy, dated December 2016, mandates that all call bells be answered promptly, which was not adhered to in this instance.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to manage the pain of Resident 137, who was admitted with a displaced fracture of the second cervical vertebra, contusion of the left hand, fibromyalgia, and pain in the left shoulder and upper arm. Upon arrival at the facility, Resident 137 did not receive the prescribed pain medication until the following day, despite requesting it during the night. The nurse informed the resident that the doctor's orders were not available, and the medication was not accessible. Throughout the resident's stay, there were multiple instances where the prescribed Norco 10-325 mg for severe pain was not administered, and instead, Norco 7.5-325 mg was given, which was intended for moderate pain. This occurred despite the resident reporting severe pain levels ranging from 7 to 10. The facility's medication administration records confirmed these discrepancies, and the pharmacy records showed that the Norco 10-325 mg was not pulled from the Cubix reserve when needed. Interviews with the nursing staff revealed a lack of effective pain management for Resident 137. LVN 2 acknowledged the resident's complaints of unmanaged pain and the unavailability of the prescribed medication. LVN 3 confirmed that the Norco 10-325 mg was not consistently available and that the resident's pain was not being managed appropriately. RN 1 also recognized the failure to administer the correct medication for severe pain and noted that the facility's process for obtaining and administering narcotic medications was not followed as expected.
Failure to Monitor Anticoagulant Use in Resident
Penalty
Summary
The facility failed to adequately monitor a resident's use of anticoagulants, leading to a deficiency in care. Resident 138, who was on apixaban for a history of deep vein thrombosis, was observed with multiple bruises on both arms. Despite the presence of these bruises, there was no documented monitoring for potential adverse effects of the anticoagulant, such as bleeding or bruising. The resident reported not receiving any instructions on monitoring for signs and symptoms of bleeding, and there was no order for baseline labs or monitoring for bleeding symptoms. Interviews with facility staff, including LVN 8, RN 1, and the ADON, revealed a lack of awareness and action regarding the resident's condition. LVN 8 admitted to not noticing the bruising, and RN 1 confirmed there was no order to monitor for bleeding signs. The ADON acknowledged that the facility's process should include monitoring for adverse effects of anticoagulants, but no such monitoring was documented for Resident 138. The facility's policy on anticoagulation therapy, which requires monitoring for signs of excessive bruising and other bleeding symptoms, was not followed in this case.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to the Enhanced Barrier Precautions (EBP) protocol during wound care for a resident, which was observed during an unannounced complaint investigation. The Treatment Nurse (TN) was seen preparing for a dressing change and wound observation for a resident who had a sign indicating EBP on the outside of their room. Although the TN donned gloves, she did not wear a gown as required by the EBP protocol during the wound care procedure. The resident involved had multiple medical conditions, including orthostatic hypotension, chronic kidney disease, Parkinson's disease, malignant neoplasm of the colon, and type 2 diabetes mellitus. The resident was also receiving palliative care and was capable of making decisions. The facility's policy required staff to use gloves and gowns for high-contact resident care activities, such as wound care, for residents with open wounds. The failure to follow these precautions had the potential to spread multi-drug resistant organisms.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, identified as Resident 2. During an unannounced visit to investigate a complaint regarding quality of care, it was observed that Resident 2's call light was on the floor, out of reach. A Certified Nursing Assistant (CNA) confirmed this observation and acknowledged that call lights should be within reach, indicating a lapse in adherence to the facility's policy. Resident 2 was admitted with multiple diagnoses, including chronic kidney disease, atrial fibrillation, pressure ulcer, osteoarthritis, Alzheimer's disease, and vascular dementia. The resident's care plan specifically noted the need for the call light to be within reach due to his musculoskeletal issues. Additionally, Resident 2's medical records indicated he lacked the capacity to understand and make decisions, further emphasizing the importance of having the call light accessible to ensure his needs could be met promptly.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by a Treatment Nurse (TN) during wound care for a resident. On June 25, 2024, the TN was observed providing skin care to a resident without performing hand hygiene after removing contaminated gloves and before donning clean gloves. This lapse in protocol occurred while the TN was applying Triamcinolone Acetonide External Cream to various areas of the resident's body, including under the breasts, groin, abdominal fold, buttocks, and sacral area. The TN acknowledged the oversight during an interview, admitting that hand hygiene should have been performed between glove changes. The resident involved had a medical history that included cellulitis of the lower limbs, a lumbar fracture, and chronic obstructive pulmonary disease (COPD). The facility's policy and procedure, as well as the Centers for Disease Control and Prevention's guidelines, clearly state the necessity of hand hygiene before and after glove use, especially when moving between different body sites. The failure to adhere to these guidelines had the potential to contaminate both the TN's hands and the resident's wounds, posing a risk of infection.
Failure to Remove CNA After Abuse Allegation
Penalty
Summary
The facility failed to ensure the immediate removal of a Certified Nursing Assistant (CNA 2) after a resident, identified as Resident A, made an allegation of sexual abuse against him. On May 5, 2024, Resident A accused CNA 2 of inappropriate behavior, including licking and looking down at her private area. Despite the allegation, CNA 2 continued to work in the presence of Resident A, causing her distress and refusal to eat. The incident was reported by CNA 1 to the Registered Nurse Supervisor (RNS) approximately two hours after it occurred, which was not in accordance with the facility's policy. Resident A, who was admitted with a diagnosis of depression and had a cognitive impairment score of 3, was visibly upset and angry upon seeing CNA 2 after the alleged incident. The facility's policy, dated October 2022, mandates the immediate removal of an employee suspected of abuse from resident care and suspension during the investigation. However, this protocol was not followed, as CNA 2 remained on duty to cover for another staff member, and the incident was not reported to the administrator immediately as required.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure physician orders were followed for one of three sampled residents, Resident A. Resident A was admitted with diagnoses including COPD, hypertension, diabetes mellitus, and atrial fibrillation. The physician orders for Resident A included Clonidine, Metoprolol, and Diltiazem, each with specific administration parameters based on blood pressure and pulse rates. However, the facility did not adhere to these orders, as evidenced by the Medication Administration Record (MAR) and interviews with staff members. On multiple occasions, Clonidine was not administered when Resident A's systolic blood pressure exceeded 160, as required by the physician's order. Additionally, Metoprolol and Diltiazem were administered even when Resident A's pulse rate was below the specified threshold of 70 beats per minute. This was confirmed through a review of the MAR, which showed instances where these medications were given despite the pulse rate being below the ordered parameters. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the staff did not follow the physician's orders correctly. The LVN acknowledged the importance of adhering to medication orders and documenting reasons for holding medications. The DON confirmed that the medications were administered incorrectly and attributed the errors to staff misreading the physician's orders. The facility's policies on medication administration and monitoring vital signs prior to administration were not followed, leading to these deficiencies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 282 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hemet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook Post Acute | 0.6 mi | ★★★★★ | 34 | 0 |
| Hemet Hills Post Acute | 0.6 mi | ★★★★★ | 7 | 0 |
| The Village Healthcare Center | 1.4 mi | ★★★★★ | 1 | 0 |
| San Jacinto Valley Post Acute | 1.7 mi | ★★★★★ | 14 | 0 |
| Devonshire Care Center | 1.7 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ramona Rehabilitation And Post Acute Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.