Ramona Rehabilitation and Post Acute Care Center

In the surveyor’s words

From the most serious findings on record at Ramona Rehabilitation and Post Acute Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 13, 2026

  Based 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.Findings:1. […]

• No harm, potential for more than minimal, patternF684Feb 13, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF759Feb 13, 2026

  Based 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. Findings:1. […]

• No harm, potential for more than minimal, patternF761Feb 13, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF880Feb 13, 2026

  Based 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. […]