Carmel Mountain Rehab: Fall Safety Failures - San Diego, CA
The incident at Carmel Mountain Rehabilitation & Healthcare Center, a skilled nursing facility on Avenue of Industry in San Diego, was documented by federal inspectors during an April 24, 2025 survey. The resident at the center of it, identified in inspection records as Resident 220, had already been flagged as a high fall risk. Her care plan required a knee immobilizer. Moving her required a gait belt.
Neither was used.
CNA 11, as the nursing assistant is identified in the inspection report, said she positioned the bedside commode at the foot of the bed, directly against the mattress. She unclipped the call light from the bedsheet and set it on top of the mattress, at the far end from where the resident would be sitting. The knee immobilizer sat in a wheelchair pushed against the wall near the head of the bed. No gait belt was in the room. No gait belt was on CNA 11.
Then she left.
CNA 11 told inspectors she stepped away to give the resident privacy after the resident asked her to. She also said she had not used a gait belt during the transfer because the resident had a walker to grab onto. Inspectors later found that Resident 220 had an unwitnessed fall in her room.
Every supervisor interviewed in the days that followed said the same thing: none of what CNA 11 did was acceptable.
The treatment nurse told inspectors on April 23 that staff should stand behind the privacy curtain or just outside the doorway for a high fall-risk resident on a bedside commode. Staff should never leave, the treatment nurse said. Gait belts should always be used when moving a high fall-risk resident.
Licensed Nurse 11 said staff should always remain in the room with a high fall-risk resident when they are out of bed.
The Director of Staff Development said she was aware of Resident 220's fall. She said the CNA should have stayed. She said if the CNA had to respond to an emergency call light, she should have told another staff member to stay with Resident 220. She said a gait belt should always be used with a resident who has limited ambulation, especially one flagged as a high fall risk.
The Director of Nursing, interviewed the morning of the inspection's final day, said Resident 220's supervision should have been better. A gait belt and the knee immobilizer should have been used. "They could have done better," the Director of Nursing said.
What makes the inspection record striking is not that a single aide made a series of errors. It is that every person in a supervisory role, when asked, gave the correct answer immediately. The rules about gait belts, about staying in the room, about what to do when a competing call light pulls you away, were not obscure. They were not disputed. The Director of Staff Development did not need to look anything up.
The rules existed. The training existed. The fall happened anyway.
Resident 220's knee immobilizer was sitting in a wheelchair against the wall when inspectors arrived for a follow-up observation on April 22. The call light was resting on the mattress, away from where she would have been able to reach it. CNA 11 demonstrated all of this herself, showing inspectors exactly where everything was placed in the moments before the resident was left alone.
The Director of Nursing's summary was four words: they could have done better.
Resident 220 was on the commode when she fell. Whether she called out, whether she reached for a call light that wasn't within reach, whether she tried to stand, the inspection report does not say. The fall was unwitnessed. Nobody was there to see 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.
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.
The resident at the center of it, identified in inspection records as Resident 220, had already been flagged as a high fall risk.
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.