Carmel Mountain Rehab: Fall Prevention Failure - San Diego, CA
The physician's order was not ambiguous. It required the immobilizer be worn whenever the resident, identified in inspection records as Resident 220, was out of bed. Getting up to use a commode placed beside the bed counted as out of bed. Everyone interviewed by inspectors agreed on that point.
The Treatment Licensed Nurse said she "would not have gotten Resident 220 up, without the knee immobilizer in place." Licensed Nurse 11 said the order was clear and "should have been implemented." The Director of Staff Development said the immobilizer was there to "support and stabilize the right leg" and the plan of care should have been followed. The Director of Nursing said the CNA "should have applied the leg/knee splint before she was assisted out of bed."
Four staff members, four consistent answers. The immobilizer should have gone on. It didn't.
Resident 220 had been assessed as a high fall risk before the fall happened, a designation the facility's own policy reserved for residents scoring in the elevated range on fall risk assessments. That score was supposed to trigger an individualized care plan with specific interventions. The knee immobilizer was one of those interventions. It existed in the care plan precisely because the facility had already determined this resident was at elevated risk of falling.
What the inspection record does not explain is how a resident with documented leg and knee fractures, flagged as high fall risk, with a physician order written into her plan of care, came to be moved to a commode without the one piece of equipment everyone agreed she needed.
The fall itself caused minimal harm, according to the inspection, conducted April 24, 2025. That classification reflects the outcome of this particular incident. It does not reflect what the fractures that preceded it cost her, or what a worse fall could have meant for a woman already dealing with a broken leg and knee.
Carmel Mountain Rehabilitation & Healthcare Center is a skilled nursing facility at 11895 Avenue of Industry in San Diego.
The violation documented here sits in a category inspectors use when a facility fails to provide the supervision and assistive devices a resident needs to prevent accidents. The inspection report notes the facility's own Fall Management System policy required individualized care plans with interventions designed to prevent falls, built around whatever put each resident at risk in the first place. For Resident 220, what put her at risk was a fractured leg. The intervention was the immobilizer. The care plan said so. The physician said so. The staff, when asked, said so.
She fell anyway.
There is a particular quality to a preventable fall in a rehabilitation setting. The resident is there, in part, because her body is already compromised. The facility has assessed the risk. The physician has written the order. The care plan exists. The equipment is available. The fall happens not because the risk was unknown or the solution undiscovered, but because the step between knowing what to do and actually doing it was skipped.
The Treatment Licensed Nurse put it plainly: if the physician ordered the immobilizer to be worn out of bed, it should have been applied. That is not a complicated standard. It requires only that the person helping a high-fall-risk resident with fractured bones move from her bed to a commode first put on the brace that was ordered, documented, and sitting there for exactly that purpose.
Resident 220 had already broken her leg once.
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: November 2, 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 physician's order was not ambiguous.
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.