Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 |
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