Carmel Mountain Rehab: Ice Scoop Contamination Risk - CA
The facility's own treatment nurse was the first to say it out loud. The scoop should be considered contaminated, she told the inspector, because it had been resting in stagnant water without a cover. If someone used it to pull ice from the chest, she said, it could contaminate all the ice. Residents could get sick.
The registered dietitian, standing at the same station two minutes later, agreed. Ice scoops should be covered, she said. The container underneath should have drainage so water doesn't pool.
What happened next is the more troubling part of the record.
By 11 that morning, the dietitian had replaced the holder at Station 2 with a clear plastic container that had a lid. No drainage was added.
The next morning, April 24, an inspector returned to Station 2 at 8:45 a.m. On the top shelf sat an uncovered square metal container. Inside it, a metal scoop. Scant water had collected at the bottom.
Twenty-five minutes later, the dietitian was back in front of the station. She told the inspector she would have kitchen staff correct it immediately and get a closed container for the scoop.
The director of nursing, interviewed that same morning, said she expected ice scoops to be covered when not in use and to have drainage. That was the standard, she said. Cross-contamination prevention.
The inspection covered two stations over two days. At each one, the problem was seen, acknowledged by staff, and either left in place or corrected in a way that didn't hold. The solution at Station 2 on April 23, a lidded container without drainage, produced the same standing water condition the following morning.
CMS classified the violation as causing minimal harm or potential for actual harm, with some residents affected.
What the record doesn't show is how long the scoops had been stored that way before inspectors arrived, or how many residents received ice drawn from a contaminated scoop before anyone checked.
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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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 treatment nurse was the first to say it out loud.
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.