Carmel Mountain Rehab: Infection Control Failures - CA
The facility failed to follow infection prevention practices when staff ignored safety requirements for a resident on Enhanced Barrier Precautions and stored ice scoops in contaminated water, creating potential for cross-contamination affecting resident health.
Resident 316 was admitted with fractured vertebrae and muscle weakness. A blue sticker outside the room and posted signage indicated Enhanced Barrier Precautions were required, meaning staff must wear gowns, gloves and masks during high-contact care to prevent bacterial spread.
On April 21 at 7:54 AM, inspectors observed Certified Nursing Assistants 31 and 32 entering Resident 316's room without performing hand hygiene or donning protective equipment. The CNAs put on gloves inside the room after entering.
Four minutes later, CNA 31 opened the resident's curtain, removed her gloves, and walked out without performing hand hygiene.
When questioned in the hallway, CNA 31 acknowledged the blue sticker meant Enhanced Barrier Precautions were required for high-contact activities. She admitted forgetting to perform hand hygiene before and after entering the room and failing to don protective equipment beforehand.
"We are supposed to gown up whether its for [brief] changes, transferring them, toileting, repositioning," CNA 31 told inspectors. "We lifted her up in bed. We should have gowned up."
CNA 32 similarly acknowledged the posted sign indicated protective equipment was required for high-contact care like mobility assistance. She stated she should have performed hand hygiene before putting gloves on and after removal.
"I honestly just forgot to [don PPE]," CNA 32 said. "I just had tunnel vision and went inside [Resident 316's room]. It always says up there [on the EBP sign posted] what you have to wear."
The facility's hand hygiene policy, dated 2021, considers hand hygiene "the primary means to prevent the spread of health care associated infections" and requires all personnel to perform hand hygiene before and after direct resident contact and after removing protective equipment.
A phlebotomy technician drawing blood from the same resident also violated protocols. On April 21 at 9 AM, the technician entered Resident 316's room wearing gloves and a surgical mask but no gown, despite Enhanced Barrier Precautions requirements.
The technician placed laboratory supplies directly on the resident's bed, then walked out carrying the container while still wearing gloves. The technician placed the container on a cart without disinfecting it first.
When questioned, the phlebotomy technician said drawing blood wasn't listed among high-contact activities on the posted signage. "I'm only drawing her blood, so I only have to wear a glove and mask," the technician stated. "I don't know exactly what she has."
The facility's Infection Preventionist clarified that the high-contact activities listed on Enhanced Barrier Precaution signage were not all-inclusive. Drawing blood was considered high-contact activity requiring gown and gloves "to avoid coming into contact with bodily fluids."
Items placed on the resident's bed should have been sanitized before placing on the phlebotomy cart because contamination could spread to other items, the Infection Preventionist explained.
Inspectors also found ice scoops stored in unsanitary conditions at two nursing stations. At Station 2 on April 21, the metal ice scoop rested inside an uncovered square metal container with one to three tablespoons of standing water. The scoop had direct contact with the stagnant water.
Similar conditions existed at Station 1, where the ice scoop sat in an uncovered metal container with accumulated water on the bottom shelf of the ice station.
A treatment nurse at Station 1 viewed the contaminated scoop container and stated there was about half an inch of water. The nurse said the scoop should be considered contaminated because it wasn't covered and was resting in stagnant water.
"If the ice scoop was used to get ice from the ice chest, it could contaminate all the ice, potentially resulting in resident's getting sick," the treatment nurse told inspectors.
The facility's Registered Dietitian agreed the ice scoops should be covered with drainage containers to prevent cross-contamination. On April 23, the dietitian replaced one ice scoop holder with a clear plastic container with a lid, but added no drainage device.
A follow-up inspection the next morning found Station 2 still using an uncovered square metal container with scant water inside the bottom. The Registered Dietitian promised kitchen staff would correct the problem immediately and obtain closed containers for ice scoops.
The Director of Nursing acknowledged staff needed to follow proper hand hygiene and Enhanced Barrier Precautions. "If they need to gown up, they are expected to gown up prior to entering the room for prevention of contamination and to practice infection control for the safety of the residents and staff," the director stated.
The facility's quality assurance program was monitoring falls, pressure ulcer reduction, weights and urinary tract infection prevention, according to administrators. However, when inspectors identified deficient trends in call light response during the survey, the Director of Nursing admitted the facility couldn't identify the root cause of call light issues.
"Identifying the root cause of the call light issues was challenging," the Director of Nursing stated, though acknowledged it was important to reduce complaints related to call light response.
The infection control violations occurred despite facility policies requiring standard precautions for all resident care, including environmental cleaning and disinfection. The facility's Enhanced Barrier Precautions policy specifically requires gown and gloves during high-contact resident care activities.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER in SAN DIEGO, CA was cited for violations during a health inspection on April 24, 2025.
Resident 316 was admitted with fractured vertebrae and muscle weakness.
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.