Carmel Mountain Rehab: Catheter Monitoring Failures - CA
His doctor had ordered it. The facility's own policy required it. It didn't happen anyway.
Resident 104, who used a catheter because he could not urinate properly after back surgery, was under a physician's order dated March 6, 2025, to have his urine output measured, monitored, and documented every shift for 30 days. The order existed because he retained fluids and had a history of bladder distention. Staff knew the risk. A nurse told inspectors that failing to track output could leave him with a distended bladder, and that monitoring was essential to his comfort and his health.
The records told a different story.
When inspectors reviewed the urine output log in late April, they found gaps across the entire monitoring period. On the overnight shift, entries were missing on March 6, 14, 18, and 19. Morning shifts went undocumented on March 8, 18, 19, 20, and 31, and then again on April 2 through April 5. Afternoon shifts showed missing entries on March 7, 8, 11, 13, and 20, and again on April 1, 2, 3, and 4.
Then came the longest gap. From March 16 through March 30, not a single shift, morning, afternoon, or overnight, had a recorded urine output entry. Fifteen consecutive days. No documentation at all.
A licensed nurse identified in the report as LN 21 reviewed the record with inspectors on April 23 and did not dispute what they found. "The staff did not consistently monitor and document his urine output per physician's order and per facility's policy," LN 21 said. The nurse explained that certified nursing assistants were responsible for emptying the catheter, collecting the urine into a urinal, discarding it in the toilet, and logging the measurement. That last step, the logging, was the one that kept failing.
The director of nursing, interviewed the following morning, said the expectation was for licensed staff to monitor the resident's output to prevent bladder distention and ensure his comfort. The DON did not explain why that expectation had gone unmet across so many shifts and so many weeks.
Resident 104 told inspectors on April 23 that he had retained fluids and experienced a distended bladder because he could not urinate properly. He described staff emptying his catheter bag into a urinal and then discarding the urine in the toilet. Whether anyone was measuring what went into that urinal before it disappeared, the records could not confirm, because for much of March, there were no records.
The facility's own intake and output policy, though undated, stated plainly that output must be recorded at the end of each shift by a licensed nurse for any resident with an indwelling catheter or as prescribed by a physician. Resident 104 met both conditions. The policy was not followed.
CMS inspectors classified the violation as causing minimal harm or potential for actual harm, the lower end of the federal harm scale. The inspection was completed April 24, 2025.
What the records cannot answer is what happened during those 15 days in March when no one wrote anything down. Whether his output was measured and simply not recorded, or whether the catheter bags were emptied without anyone noting the volume at all, the log offers no evidence either way. A man on a fluid restriction of two liters per day, with a documented history of retaining fluids, went through half a month of recovery at a licensed rehabilitation facility with no documented evidence that anyone was watching how his body was handling the fluid moving through it.
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.
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Last verified: October 29, 2026 · Our methodology
CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER in SAN DIEGO, CA was cited for violations during a health inspection on April 24, 2025.
The facility's own policy required it.
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.