Carmel Mountain Rehab: Call Light, Cold Food Failures - CA
That's what Resident 104 told inspectors at Carmel Mountain Rehabilitation & Healthcare Center during a federal health inspection completed April 24, 2025. She was cognitively intact, fully aware of what was happening around her, and she needed help transferring from her bed to her wheelchair. She couldn't do it alone.
"Sometimes they answer, they will say I'm helping another resident, and they don't come back," she told inspectors. "Or if they come back, they come back in two hours."
She also said she thought the facility was short-staffed.
A nursing assistant who worked with Resident 104 confirmed to inspectors that the resident was alert and oriented, and that she required staff assistance to move from her bed to her wheelchair. The nursing assistant offered no explanation for the delays.
When the Director of Nursing was interviewed the following day, she said the expectation was that call lights be answered in a timely manner, and that meeting residents' needs was both their right and a matter of safety. She did not tell inspectors what had gone wrong or what had been done about it.
The call light failures were one of two patterns inspectors documented during the four-day inspection. The other involved food.
On the morning of April 21, inspectors watched kitchen staff wheel a breakfast cart out to a unit hallway at 8:06 a.m. It sat there. Thirty-three minutes passed before two nursing assistants began distributing trays to the roughly 25 residents on the unit.
By mid-afternoon, Resident 317 described what that delay had meant for her morning. "This morning I just ate my cereal," she said. "I didn't eat the eggs because they were ice cold. The trays are always cold."
The word "always" carried weight. This wasn't a one-morning complaint.
The following day, during a Resident Council meeting, the council representative raised the same issue. Some days, he said, it takes a while for staff to bring the meal trays out. The morning shift has so much to do that they can't get the food out on time. His own tray, he said, was often cold when it arrived.
The Director of Nursing, interviewed again on April 24, said staff should have distributed trays immediately once the cart arrived on the unit, or at least told someone the cart was there. "We don't want the residents to have cold food," she said.
The cart had been sitting in the hallway for over half an hour. No one had communicated anything. No one had acted.
What the inspection captured, across both findings, was a facility where the gap between stated expectations and daily reality had become wide enough that residents were tracking it themselves, describing it in interviews, raising it in council meetings. Resident 104 had learned the rhythms of the call light system well enough to know that a response was not the same as help, and that help, when it came, might take two hours. Resident 317 had stopped ordering eggs.
The inspection found the level of harm to be minimal harm or potential for actual harm, and noted that some residents were affected. The deficiencies fell under the facility's obligations to accommodate residents' needs and to provide services that maintain dignity.
Carmel Mountain Rehabilitation & Healthcare Center is located at 11895 Avenue of Industry in San Diego.
Resident 104 required staff assistance to move. She pressed the call light. She waited.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carmel Mountain Rehabilitation & Healthcare Center from 2025-04-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 26, 2026 · Our methodology
CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER in SAN DIEGO, CA was cited for violations during a health inspection on April 24, 2025.
That's what Resident 104 told inspectors at Carmel Mountain Rehabilitation & Healthcare Center during a federal health inspection completed April 24, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.