Ramona Rehabilitation and Post Acute Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in accordance with professional standards of practice, when:1. The convection oven had splattered, solidified greasy residue on the glass doors and black crusted residue at the bottom of the oven; and2. One opened package of white loaf bread with a date of January 30, 2026, was found stored on the shelf, readily available for use. The opened package of the white loaf bread did not have an open date and a use-by date. These failures had the potential to cause foodborne illnesses (stomach illness resulting from ingestion of contaminated food) in a medically vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for four of 97 residents reviewed, when:1. For Resident 51, the facility did not provide ongoing assessment and monitoring for bilateral (both) lower extremities edema (swelling caused by too much fluid trapping in the body's tissues);2. For Resident 104, the facility did not provide ongoing assessment and monitoring for bilateral upper and lower extremities, and low blood pressure;3. For Resident 112, the facility did not notify the physician of the resident's change in level of consciousness; and4. For Resident 55, the facility did not identify, address, and notify the physician of the left elbow skin discoloration on February 10, 2026. These failures had the potential for a delay in treatment and placed the residents at risk of complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders and the facility's policies and procedures, when a medication error rate of 11.9% was identified, with five medication errors out of 42 medication administration opportunities, during medication pass observations for two of five residents observed (Residents 32 and 47). These failures included administration of incorrect medication, incorrect dosage form, and omissions of ordered medication while documenting them as administered, which had the potential to compromise residents' medication therapy and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with the facility's policies and procedures and manufacturer's specifications, when:1. An insulin (medication to treat diabetes mellitus [abnormal blood sugar]) pen was stored in the Medication Cart at Nursing Station 3 without documentation of the date removed from refrigeration;2. Two discontinued controlled substances (CS - those with high potential for abuse and addiction) were stored in the Medication Cart at Nursing Station 4 with other active medications; and3. A single-use plastic vial of Levalbuterol inhalation solution was stored without a prescription label, without light protection, and without documentation of the date removed from its protective foil pouch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented for seven out of 97 residents reviewed for infection control practices when:1. For Residents 47 and 108, nursing staff did not clean and disinfect shared medical equipment, including a blood pressure (BP) cuff and stethoscope (medical instrument for listening to the action of someone's heart or breathing, typically having a small disk-shaped resonator that is placed against the chest, and two tubes connected to earpieces), before and after use, in accordance with the facility's infection control policy;2. Certified Nursing Assistant (CNA) 2 did not perform hand hygiene in between serving food trays to four residents in Station 2 during the lunch meal service on February 9, 2026; and3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician evaluated and documented the clinical rationale supporting the continued use of the as-needed (PRN) lorazepam (a psychotropic medication used to treat anxiety) beyond 14 days, for one of five residents reviewed for unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications (Resident 28). This failure had the potential to result in unnecessary use of psychotropic medications and increased risk for adverse effects, including sedation, confusion, and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered and documented in accordance with the physician orders and the facility policy when the nursing staff administered an as-needed (PRN) medication but failed to document the administration in the Medication Administration Record (MAR), for one of six residents observed during medication administration (Resident 108). This failure resulted had the potential to compromise pain management, delayed evaluation of medication effectiveness, and increased the risk of duplicate dosing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) December 2025 Medication Regiment Review (MRR) recommendations were reviewed and acted upon in a timely manner, for two of five sampled residents (Residents 28 and 79). This failure had the potential to result in unresolved medication-related issues due to delayed evaluation of medication therapy and compromised resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served met the individual needs. for one of three residents (Resident 109), when the kitchen staff did not follow the diet spreadsheet during the tray line observation on February 11, 2026, for residents on renal diet (diet for patients with kidney disease by limiting potassium, phosphorus, and protein to reduce waste in the blood). This failure had the potential to compromise Resident 109's nutritional and health status.

Inspectors wroteBased on interview and record review, the facility failed to evaluate and develop new interventions for one of three sampled residents (Resident 1), who has poor decision making, high risk for fall, and had fall incidents on June 16 and June 22, 2025. This failure placed Resident 1 at risk for further falls which could result in serious injury while at the facility. On July 10, 2025, at 9:05 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality-of-care issues. On July 10, 2025, Resident 1's record was reviewed. Resident 1's admission Record, indicated Resident 1 was admitted on [DATE], with diagnoses which included prosthetic aortic valve replacement (surgery to restore proper blood flow through the heart), acute kidney disease (a condition the kidneys cannot filter waste from the blood) and dementia (impaired thinking abilities, forgetfulness). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure intravenous (IV - fluids/medication given directly into the bloodstream) antibiotic medications was provided according to the physician's orders upon discharge from the General Acute Hospital (GACH), for one of five residents (Resident A). This failure resulted in Resident A not receiving the IV antibiotics as prescribed, and needed to extend the IV medication to address Resident A's infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of physical abuse was reported to California Department of Public Health (CDPH) immediately, but not later than two (2) hours after the allegation was made. The facility was made aware of the alleged physical abuse of a facility staff (Certified Nursing Assistant [CNA] 1) to a resident (Resident 1) on October 28, 2024. This failure had the potential to cause a delay in the investigation of the alleged abuse and to expose residents in the facility to further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment was conducted, for three of six residents (Resident 20, 30, and 33) reviewed for safe self-administration of medication when: 1. One 30 ml (milliliters - unit of measurement) cup of powder medication was found on the bedside table of Resident 20; 2. One opened tube of Desitin (brand of ointment used to prevent and treat rash) 57 GM (gram-unit of measurement) ointment was found on bedside table of Resident 30; and 3. One opened bottle of 15 ml eyedrops (medication that relieves eye irritation) was found on the overbed table of Resident 33. These failures had the potential for Residents 20, 30, and 33 to receive multiple doses of medication without proper monitoring, which could lead to harmful effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired, discontinued, and unlabeled medications and intravenous (IV- into the vein) fluids were not readily available for use. These failures have the potential for the residents to receive wrong, contaminated, expired, or ineffective medication therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage practices were followed in the kitchen when: - One seven-pound (lb- unit of measurement) can of cranberry jelly was found in the dry storage area undated; - Two stalks of celery in a plastic bag were found in the walk-in refrigerator with the bag open exposing the celery to air; and - Five three-lb bars of chopped spinach were found in the freezer not dated. These failures had the potential to cause food-borne illnesses in a highly susceptible resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) 2 did not use personal protective equipment (PPE - equipment use to protect against infection or illness) when providing care to a resident requiring enhanced barrier precautions (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO- bacteria that have become resistant to multiple antibiotics]); 2. The Laundry Staff (LS) failed to follow proper handling and storage of clean linens; 3. The Certified Occupational Therapy Assistant (COTA - healthcare provider who performs physical movement) did not conduct proper handwashing before and after providing therapy treatment to a resident; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat resident with respect and dignity when the staff failed to cover the urinary bag, for one of one resident reviewed for dignity (Resident 53). This failure increased the potential to negatively affect Resident 53's psychosocial wellbeing.

Inspectors wroteBased on interview and facility policy review the facility failed to answer the call light within a reasonable time, for one of 95 residents (Resident 34). This failure had the potential to not meet the resident's needs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to manage the pain, for one of three residents reviewed for pain (Resident 137), when the pain medication was not administered according to the physician's order. This failure resulted in Resident 137 not receiving the pain medication as ordered by the physician and had the potential for Resident 137 to experience pain not to be managed appropriately and affect overall health condition.

Inspectors wroteBased on observation, concurrent interview, and record review, the facility failed to monitor for anticoagulant (medication that treats blood clots) use, for one of two residents reviewed (Resident 138), when Resident 138 was observed to have multiple bruises on both arms. This failure resulted in Resident 138 not being monitored for potential harmful side effects of anticoagulants.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow orders for enhanced barrier precautions, (EBP - the use of gown and gloves for residents that have chronic wounds, or indwelling devices during high-contact procedures to prevent the spread of multi-drug resistant organisms in nursing homes) for one of three residents (Resident 7), during wound care. This failure had the potential for the spread of multi-drug resistant organisms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of three sampled residents, (Resident 2). This failure had the potential to result for Resident 2's needs being unmet, and the inability to call for help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Treatment Nurse (TN), followed infection control guidelines when she did not perform hand hygiene after removing contaminated gloves and prior to donning clean gloves for during wound care for one of three residents, (Resident 5). This failure had the potential to contaminate the TN's hands and the resident's wounds.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of three sampled residents (Resident A), the staff removed the Certified Nursing Assistant (CNA 2) after the resident made an allegation of sexual abuse against the CNA. This failure resulted in Resident A seeing CNA 2, causing the resident to become upset and angry.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were followed for one of three sampled residents. This failure had the potential to cause further complications for Resident A's heart rates and blood pressures.

Inspectors wroteBased on interview and record review the facility failed to weigh one (Resident A) out of three residents, on admission and every week for the first four weeks, in accordance with the policy and procedure. This failure had the potential for Resident A to not receive treatment and care in accordance with professional standards of practice.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a COVID-19 outbreak was reported to California Department of Public Health (CDPH). This failure had the potential for CDPH not to be aware of the facility needs related to staffing, protective equipments, and technical assistance during the outbreak situation at the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow facility policy and procedure in assessing the need for a pneumococcal vaccine within five working days of admission, for one of five residents (Resident 1). This failure had resulted for the resident not to be afforded the benefit of receiving a pneumococcal vaccine, placing the resident at risk for pneumococcal infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of three sampled residents (Resident 1): A. Resident 1's third toe discoloration on the right foot identified by staff on September 16, 2023, was addressed and referred to the physician for appropriate care and treatment. In addition, Resident 1's third toe discoloration on the right foot had an ongoing assessment and evaluation . B. Resident 1's new skin discoloration to the third and fourth toes observed by the Certified Nursing Assistant (CNA) on September 27 2023, was reported to the licensed nurse. These failures had the potential for the delay in necessary care and treatment of the right third and fourth toe and possible complication like amputation.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from potentially dangerous drug-drug interactions and duplication of therapy when two similar medications for COPD (congestive obstructive pulmonary disease - chronic lung disease that causes obstructed airflow from the lungs) were ordered and administered to one of five residents reviewed (Resident 288). This had the potential to cause harm to the resident from the side effects after receiving more than what was recommended by drug manufacturers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained and food was stored in accordance with professional standards for food service safety when: 1. Food items were not appropriately labeled with the use by date; 2. An open plumbing fixture under the kitchen sink had aluminum foil in the vacant hole and needed to be replaced and repaired; 3. One expired plastic container of ground turmeric was found in the dry storage area and readily available for use; 4. Two air gaps (space between the water outlet and the flood level of a fixture) required cleaning and/or repair; 5. The ice machine was found to have a light brown residue around the inner rim of the door; and 6. One cook did not perform hand hygiene during the lunch tray line observation when touching the plates and plate covers after using two oven mittens. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash containers were not overfilled and the lids were kept securely closed to prevent the potential attraction of pests and vermin (nuisance animals that could spread diseases). This facility failure increased the potential for attracting insects and vermin, which could result in food-borne illnesses in a highly susceptible population of 90 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform proper hand hygiene after providing care for one of three residents reviewed (Resident 51) on contact transmission-based isolation precautions. This failure had the potential to result in transmission of infectious illnesses to the vulnerable population of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. One medication order was duplicated in the medical record of Resident 28. This had the potential to increase the side effects from receiving more than the prescribed dose by the physician; and, 2. Discontinued medications were left in the medication cart for resident use. This had the potential for residents to receive wrong medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided meet the storage of medications at the bedside, for one of 24 residents (Resident 10) reviewed, when the medication Afrin (nasal spray to relieve congestion) was observed at the bedside. This failure had the potential for Resident 10 to experience side effects after receiving a medication without a physician's order.