Other·October 2, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an annual recertification survey conducted on July 22 to 25, 2019. Representing the California Department of Public Health: Surveyor, 41348, HFEN; Surveyor, 37626, HFEN; Surveyor, 32192, HFEN; Surveyor, 36779, HFEN; Surveyor, 40674, HFEN; Surveyor, 40988, HFEN; Surveyor, 41422, HFEN; Surveyor, 42082, HFEN; Surveyor, 25338, HFES; and Surveyor, 25281, Pharmaceutical Consultant II. The facility census was 84.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 08/16/2019 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 1 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 2 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 3 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to provide written notification to the resident or her responsible party (RP), and the Office of the State Long Term Care (LTC) Ombudsman, of the plan to transfer a resident to a general acute care hospital (GACH), for one of three residents reviewed for hospitalization (Resident 3). These failures resulted in Resident 3 or her RP to not be aware of Resident 3's right to appeal and have access to an advocate at the Office of the State LTC Ombudsman. Findings: On July 25, 2019, Resident 3's record was reviewed. The facesheet indicated Resident 3 was originally admitted to the facility on April 7, 2019, with diagnoses including Alzheimer's dementia (memory loss). The document titled, "Progress Notes," dated April 17, 2019, at 2:45 p.m., indicated, "...cardiology (Resident 3's heart doctor) sent (Resident 3) to hospital due to abnormal findings..." There was no documented evidence the facility provided Resident 3 or her RP, and the Office of the State LTC Ombudsman, a written notification of Resident 3's transfer to the GACH on April 17, 2019. On July 25, 2019, at 11:10 a.m., an interview was conducted with the Director of Behavioral Health (DBH). The DBH confirmed Resident 3's physician sent her to a GACH on April 17, 2019. The DBH stated she and the nursing staff were responsible for providing written notifications of proposed transfers or discharges to the residents or their RP's. The DBH stated she did not do "the form" (written notification of proposed transfer/discharge) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 4 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when Resident 3 was transferred to the GACH on April 17, 2019. When asked if written notification regarding Resident 3's transfer to the GACH was provided to Resident 3 or her RP, the DBH stated she would look into it. The DBH stated the Receptionist was responsible for faxing a copy of the written notification to the Office of the State LTC Ombudsman. On July 25, 2019, at 1:30 p.m., an interview was conducted with the DBH. The DBH stated she did not find Resident 3's "form" on written notification of proposed transfer/ discharge. The DBH stated she did not know of any documentation the facility provided Resident 3 or her RP a written notification of her transfer to a GACH on April 17, 2019, including her rights to appeal and contact information for the Office of the State LTC Ombudsman. On July 25, 2019, at 3:09 p.m., an interview was conducted with the Receptionist. The Receptionist stated she was responsible for faxing a copy of the written notifications of a resident's proposed transfers/discharges to the Office of the State LTC Ombudsman. The Receptionist stated the Office of the State LTC Ombudsman was not notified of Resident 3's transfer to a GACH on April 17, 2019, On July 25, 2019, the facility policy and procedure titled, "TRANSFER AND DISCHARGE NOTICE," dated November 2017, was reviewed. The policy indicated, "...A written notice of transfer or discharge shall be provided to the resident and resident's representative(s)...When a resident is temporarily transferred on an emergency basis to an acute care facility, the written notice is to be provided as soon as practicable. Copies of these notices are to be sent to the State LTC Ombudsman Office..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 5 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/16/2019 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 279) did not develop a pressure ulcer (bedsores) when he was positioned on a bedpan for forty-five minutes. This failure resulted in Resident 279 developing pressure ulcers on both buttocks. Findings: On July 22, 2019, at 11:03 a.m., Resident 279 was observed lying in bed and alert. During a concurrent interview with Resident 279, Resident 279 was able to state his full name, the time, the place, and the reason why he was admitted to the facility. Resident 279 stated he was admitted to the facility for rehabilitation after a hip fracture (broken bone). Resident 279 stated he was given the "wrong bedpan" and he developed a bedsore on his "tailbone." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 6 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On July 22, 2019, starting at 11:50 a.m., wound care observation was conducted in Resident 279's room with Licensed Vocational Nurse (LVN) 1. Resident 279's right buttocks was observed to have an area which was purplish in color and had no open skin area. Resident 279's left buttocks was observed to be purplish in color with a partially open area which was reddish in color. During a concurrent interview with LVN 1, she stated, "it's facility acquired wounds on both buttocks and staged as unstageable ulcers (skin loss with slough [product of dead tissue] and/or eschar [scab] at the base of the wound; the color of the surrounding area may be different from the wound bed)." On July 23, 2019, at 3:09 p.m., Resident 279 was interviewed. Resident 279 stated he was given a fleets enema (liquid laxative [medication for constipation] administered through the anus) last week after lunch at "approximately between 12 p.m. to 3 p.m." Resident 279 stated he was given a fracture bedpan (a bedpan smaller than a regular bedpan and used for someone with hip fracture). Resident 279 stated he was told by the facility staff he was given the fracture bedpan "just in case I have bowel movement." Resident 279 stated he was on the bedpan for "approximately 45 minutes." Resident 279 stated he felt uncomfortable when he was on the bedpan so he turned his call light button on. Resident 279 stated nobody checked on him while he was on the bedpan until he put his call light on. Resident 279 stated when the facility staff went into his room to remove the fracture bedpan, he was told by the facility staff he had "red marks on his buttocks." Resident 279 stated he was not happy that he got the wounds. On July 23, 2019, at 4 p.m., Certified Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 7 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Assistant (CNA)1 was interviewed. CNA 1 stated he would check the resident every five to ten minutes if the resident was put on a bedpan. On July 23, 2019, at 4:01 p.m., CNA 2 was interviewed. CNA 2 stated she would check the resident every 30 to 45 minutes if the resident was put on a bedpan. On July 24, 2019, CNA 3 was interviewed. CNA 3 stated she would check the resident five minutes after she put the resident on a bedpan. On July 24, 2019, at 10:15 a.m., LVN 2 was interviewed. LVN 2 stated the CNA assigned on the afternoon shift (3 p.m. to 11 p.m.) on July 18, 2019, placed Resident 279 on a fracture bedpan. LVN 2 stated she did not know how long Resident 279 was on the bedpan. LVN 2 stated Resident 279's pressure ulcers "should have been prevented if the CNA went to check the resident sooner." On July 24, 2019, at 10:25 a.m., CNA 2 was interviewed. CNA 2 stated on July 18, 2019, she worked the afternoon shift. CNA 2 stated at approximately 3:30 p.m. on July 18, 2019, she went to answer the call light of Resident 279. CNA 2 stated Resident 279 told her, he was on the bedpan, he was given a laxative, and he felt uncomfortable on the bedpan. CNA 2 stated she checked Resident 279 and she noticed he was leaning towards his side and she saw the fracture bedpan was placed crooked so she repositioned the fracture bedpan. CNA 2 stated the fracture bedpan was too small for Resident 279 so she told Resident 279 she would get him a bigger bedpan. CNA 2 stated she returned to Resident 279 and replaced the fracture bedpan with a regular bedpan. CNA 2 stated she went to check Resident 279 ten minutes after she placed him FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 8 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on the regular bedpan. CNA 2 stated she did not check Resident 279's buttocks before she replaced the fracture bedpan with a regular bedpan. CNA 2 stated when she removed the regular bedpan, she noticed red marks on Resident 279's buttocks. On July 24, 2019, at 12:09 p.m., the Director of Nursing (DON) was interviewed. The DON stated she was aware of Resident 279's pressure ulcers caused by the extended use of a bedpan. The DON stated Resident 279's pressure ulcers could have been prevented if the CNA checked Resident 279's skin when she replaced the fracture bedpan and if the resident was not left on the bedpan for an extended time. On July 24, 2019, at 4:44 p.m., Resident 279 was interviewed. Resident 279 stated he could not recall which facility staff put him on the bedpan. Resident 279 stated that he was almost positive he was put on the bed pan by the first shift (7 a.m. to 3 p.m.). Resident 279 stated the shift ended and nobody went back to check him or they forgot about him. Resident 279 stated he was in excrutiating pain from the skin contact with the bedpan. On July 24, 2019, at 5:13 p.m., a follow up interview was conducted with LVN 2. LVN 2 stated she worked the morning shift on July 18, 2019. She stated she administered a fleets enema to Resident 279 on July 18, 2019, at 2:45 p.m. LVN 2 stated she put Resident 279 on a fracture bedpan at approximately 2:55 p.m. on July 18, 2019 (inconsistent with her own statement during the interview on July 24, 2019, at 10:15 a.m.). LVN 2 stated she reported she administered a fleets enema and put Resident 279 on the bedpan to LVN 4. LVN 2 stated she did not report to a CNA that Resident 279 was on the bedpan. LVN 2 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 9 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 279 did not have any skin condition before she administered the fleets enema to him. On July 24, 2019, at 5:37 p.m., a follow up interview was conducted with CNA 2. CNA 2 stated she could not recall if there were red marks on Resident 279's buttocks when she replaced the fracture bedpan with a regular bedpan on July 18, 2019. On July 24, 2019, at 6:40 p.m., LVN 3 was interviewed. LVN 3 stated she worked double shifts (7 a.m. to 11 p.m.) on July 18, 2019. LVN 3 stated the report she received from LVN 4 did not include Resident 279 was on a bedpan. LVN 3 further stated she did not receive a change of shift report from LVN 2. LVN 3 stated CNA 2 notified her Resident 279 had red marks on his buttocks. LVN 3 stated she went to assess Resident 279's buttocks and noticed red and burgundy discoloration which appeared to be bedpan marks on Resident 279's buttocks. On July 25, 2019, at 9:38 a.m., LVN 4 was interviewed. LVN 4 stated she worked the 3 p.m. to 11 p.m. shift on July 18, 2019. LVN 4 stated she received report from LVN 2 (outgoing nurse) on July 18, 2019. LVN 4 stated she received report a fleets enema was administered on Resident 279 by LVN 2. LVN 4 stated she did not receive report Resident 279 was placed on a bedpan. On July 25, 2019, at 10:30 a.m., wound care observation was conducted with LVN 1 in Resident 279's room. Resident 279's left and right buttocks wounds were observed to have open areas. The wound on the left buttock measured approximately nine centimeter [cma unit of measurement]) by one cm, with the open area measuring approximately six cm by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 10 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE one cm. The wound on the right buttock measured approximately five cm by one cm, with an open area measuring three cm by one cm. During a concurrent interview, LVN 1 described both left and right buttocks wounds as deep tissue injury (DTI- purple or maroon localized area of intact skin or blister due to pressure on the underlying tissue). Resident 279's record was reviewed. Resident 279's "ADMISSION RECORD," indicated Resident 279 was admitted to the facility on July 12, 2019, with diagnoses which included displaced fracture of the neck of left femur (broken bone of the upper leg) and morbid obesity (overweight). Resident 279's "Nursing Admission Screening/History," dated July 12, 2019, indicated Resident 279 did not have pressure ulcers upon admission. Resident 279's "HISTORY AND PHYSICAL," dated July 16, 2019, indicated "...PATIENT MENTALLY CAPABLE OF UNDERSTANDING? YES..." Resident 279's "Medication Administration Record (MAR)," dated July 2019, indicated a fleets enema was administered to Resident 279 on July 18, 2019, at 2:45 p.m. The facility document, "SBAR (Situation, Background, Assessment, Request) Communication Form and progress note," dated July 18, 2019, at 6:27 p.m. was reviewed. The document indicated, "(Resident 279's name)...discoloration to bilateral (both) buttock (sic)..." Resident 279's "Minimum Data Set (MDS- an assessment tool)," dated July 19, 2019, indicated Resident 279 had a "Brief Interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 11 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for Mental Status" score of 15 (a score of 1315 meant Resident 279's cognition [thinking] was intact). The facility document titled, "Weekly Wound Report," dated July 19, 2019, was reviewed. The document indicated, "(Resident 279's name)...Location: right buttock...Indicate whether this site was acquired during the residents stay...Acquired...Date acquired: 07/18/2019 (July 18, 2019)...Comments 100% (percent) intact maroon discolored skin...COMMENTS DTI pressure ulcer/injury caused by patient laying on a fractured (sic) bedpan for an extensive period of time..." The facility document, "Weekly Wound Report," dated July 19, 2019, was reviewed. The document indicated, "...(Resident 279's name)...Location: left buttock...Indicate whether this site was acquired during the residents stay...Acquired...Date acquired: 07/18/2019 (July 18, 2019)...Comments: 100% intact maroon discolored skin...COMMENTS DTI pressure ulcer/injury caused by patient laying a fractured (sic) on a bedpan for an extensive period of time..." The facility policy titled, "CHANGE OF SHIFT REPORT," revised March 1998, was reviewed. The policy indicated, "...It is the policy of this facility that a verbal report on resident status will be given by the on-duty nurses to the oncoming nurses at each change of shift, in order to provide communication and continuity of resident care regarding...change of condition...any unusual occurence or event..." The facility policy titled, "PRESSURE ULCER MANAGEMENT PROGRAM," revised December 11, 2011, was reviewed. The policy indicated, "...It is the policy of this facility to have a system of evaluation, assessment and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 12 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE monitoring of residents for pressure sore management and/or prevention..."

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 08/16/2019 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure pain medication was administered timely when a resident complained of pain for one of four residents reviewed for pain (Resident 3). This failure resulted in Resident 3 experiencing pain for longer than necessary. Findings: On July 22, 2019, Resident 3's record was reviewed. The record indicated Resident 3 was readmitted to the facility on April 19, 2019, with diagnoses including chronic obstructive pulmonary disease (a disease of the lungs). On July 23, 2019, at 10:14 a.m., Resident 3 was observed to have facial grimacing and was groaning while lying in bed in her room. During a concurrent interview with Resident 3, Resident 3 stated she had pain. When asked to rate her pain on a scale of zero to ten in which zero was no pain and ten was the worst pain, Resident 3 stated her pain was a "nine." Resident 3 showed the area at her left lower rib cage and stated it was "hard" and "it hurts." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 13 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 3 was observed crying at times during the interview. Certified Nurse Assistant (CNA) 4 entered Resident 3's room while Resident 3 was being interviewed. In a concurrent interview with CNA 4, CNA 4 stated she had told Licensed Vocational Nurse (LVN) 5 Resident 3 was in pain. On July 23, 2019, at 10:41 a.m., an interview with Resident 3 was attempted. Resident 3 stated she was in pain and was unable to continue the interview. Resident 3 was observed to be crying intermittently. On July 23, 2019, a review of Resident 3's record was conducted. The "Order Summary Report," dated July 23, 2019, included a physician's order which indicated, "...HYDROcodone-Acetaminophen (Norco - a pain medication) Tablet...Give 1 (one) tablet by mouth every 4 (four) hours as needed for PAIN....start...04/08/2019 (April 8, 2019)." The document titled, "Progress Notes," dated July 23, 2019, included an entry by LVN 5 at 10:12 a.m. The documentation indicated, "...Resident continues to c/o (complain of) left rib cage pain...States when she takes a deep breath or moves around her rib cage hurts. Tender to touch..." The document titled, "PRN (as needed) PAIN ASSESSMENT," dated July 2019, was reviewed. The document indicated Resident 3's pain level on July 23, 2019, at 12 p.m. was "Moderate (4 - 6)." The document titled, "Medication Administration Record (MAR)," dated July 2019, was reviewed. The document indicated Resident 3 received a dose of Norco at 12 p.m., on July 23, 2019. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 14 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On July 23, 2019, at 3:20 p.m., an interview was conducted with LVN 5. LVN 5 stated she first became aware Resident 3 was in pain at about 10 a.m. on July 23, 2019. LVN 5 stated Resident 3 had a pain of "seven" (on a scale of 0 - 10, in which 7 - 10 was severe pain). LVN 5 stated she did not give Resident 3 a dose of Norco at that time. LVN 5 stated she gave a dose of Norco "later." LVN 5 confirmed she gave a dose of Norco at 12 p.m. (two hours after first becoming aware Resident 3 was in pain). On July 25, 2019, at 1:48 p.m., an interview was conducted with Assistant Director of Nurses (ADON) 1. When asked when LVN 5 should have given a dose of Norco to Resident 3 after the licensed nurse first become aware Resident 3 was in pain at 10 a.m., on July 23, 2019, ADON 1 did not answer. ADON 1 stated she would have given Resident 3 a dose of Norco when she first became aware Resident 3 was in pain. The facility policy and procedure titled, "PAIN MANAGEMENT," dated December 11, 2011, was reviewed. The policy indicated, "...Our facility philosophy of pain management is not only the relief of pain, but also the maintenance of quality of life. The goal of pain management is to reduce the pain to the lowest possible level as determined by the resident..."

F804 SS=E Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) 08/16/2019 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 15 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to provide food that was palatable when seven of 82 residents (Residents 24, 67, 64, 478, 15, 41, and 18) who eat food from the kitchen complained the food was bland. These failures increased the potential for Residents 24, 67, 64, 478, 15, 41, and 18 to not have adequate nutritional intake. Findings: On July 22, 2019, at 10:56 a.m., Resident 24 was interviewed. Resident 24 stated the facility food was bland. On July 22, 2019, at 11:28 a.m., Resident 67 was interviewed. Resident 67 stated the facility food was "very bland." On July 22, 2019, at 4:01 p.m., Resident 64 was interviewed. Resident 64 stated, "The food was tasteless." On July 24, 2019, at 1 p.m., during tray line observation, a test tray (a meal tray ordered to sample the food served to the residents) with a regular diet meal was requested. The test tray included beef stroganoff, cooked zucchini, and ice cream. On July 24, 2019, at 1:24 p.m., the Food and Nutrition Service Director (FNSD) sampled the food items. During a concurrent interview, the FNSD stated, "The beef stroganoff could use salt." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 16 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On July 24, 2019, at 1:35 p.m., Resident 478 was interviewed. Resident 478 stated the beef stroganoff was "a little bland." On July 24, 2019, at 1:40 p.m., Resident 15 and Resident 41 were concurrently interviewed. Resident 15 and Resident 41 both stated the beef stroganoff was "a little bland." On July 24, 2019, at 1:42 p.m., Resident 18 was interviewed. Resident 18 stated, "The beef stroganoff was lousy." The facility document titled, "Diet Type Report," dated July 22, 2019, was reviewed. The document indicated Resident 24 was on a regular diet. The document also indicated Residents 67 and 64 were on no added salt and consistent carbohydrate diet (diet containing the same amount of carbohydrates in each meal to help to control blood sugar). The facility document titled, "Daily Cook's Menu," dated Summer 2019, was reviewed. The document indicated, "...NO ADDED SALT DIET: follow Regular Diet and omit salt packets at all meals..."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 08/16/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 17 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained when: 1. The ice machine had yellow gelatinous debris in the ice chute; 2. One dietary staff did not have facial hair covering while in the food preparation area; and 3. The quaternary ammonium (Quat- a sanitizing agent) test strip used to test the chemical concentration of the sanitizing solution was labeled with an expiration date of May 2018. These failures had the potential to result in cross contamination and food borne illness in a highly susceptible resident population of 82 who ate food prepared in the facility kitchen. Findings: 1. On July 22, 2019, at 9:45 a.m., during an inspection of the facility's ice machine, conducted with the Food and Nutrition Service Director (FNSD), yellow gelatinous debris substances was observed inside the ice chute. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 18 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE In a concurrent interview with FNSD, she stated, "The yellow gelatinous debris should not be in the ice chute." On July 22, 2019, at 9:49 a.m., an interview was conducted with the Maintenance (Maint). The Maint stated the ice machine was serviced for cleaning every six months. The Maint stated, in June 2019, the service technician recommended increasing the frequency of cleaning service for the ice machine to more often than every six months. According to the 2017 Food and Drug Administration (FDA) Food Code, "...equipment contacting food such as... ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold..." 2. On July 22, 2019, at 10:05 a.m., during the initial kitchen tour conducted with the FNSD, Cook 1 was observed with facial hair on the chin that appeared to be ¼ inch with some hair observed to be longer. Cook 1 was observed not wearing a covering on his beard. On July 22, 2019 at 10:30 a.m., the FNSD was interviewed. The FNSD stated, "It did not matter the length of the facial hair. It should be covered." According to the 2017 FDA Food Code, "... FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD..." 3. On July 24, 2019, at 9:15 a.m., a follow-up kitchen observation was conducted with the FNSD and Dietary Aide (DA) 1. DA 1 was asked to demonstrate the sanitation process. DA 1 was observed to remove a Quat test strip FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 19 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056214 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RAMONA REHABILITATION AND POST ACUTE CARE CENTER 485 W Johnston Ave Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE from an unbranded container and dipped the test strip into a bucket filled with water and quaternary ammonium solution. DA 1 was observed to compare the color of the strip with the color legend on the bottle. DA 1 stated the test strip was currently being used. The Quat test strip was observed with an expiration date of May 2018. On July 24, 2019, at 9:19 a.m., a follow up interview was conducted with the FNSD. The FNSD stated the Quat test strips with an expiration date of May 2018, should not have been used. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VNW611 Facility ID: CA240000141 If continuation sheet 20 of 20