Carmel Mountain Rehab: Missed IV Antibiotic Doses - CA
The resident, identified in inspection records as Resident 97, was receiving Merrem, an intravenous antibiotic used to treat serious bacterial infections. The physician's order required the PICC line, a catheter threaded into a large vein to deliver the drug directly into the bloodstream, to be flushed with each antibiotic dose. Neither the medication administrations nor the flushes were documented for April 1, 2, or 3.
A licensed nurse, identified in the report as LN 22, told inspectors she found no documentation from other nurses showing the medications had been given or that PICC line care had been performed on any of those three days. Her summary of what that meant was direct: "If it was not documented, it was not given."
That is the standard the nursing profession applies to its own records. A medication entry that doesn't exist is treated as a medication that was never given.
The PICC line flush requirement wasn't incidental. When a PICC line is not flushed regularly, it can clot. A clotted line cannot deliver medication. In Resident 97's case, the flush was ordered specifically to coincide with each antibiotic dose, meaning every missed dose potentially meant a missed flush, and every missed flush meant the line itself was at risk of becoming useless for the treatment it was placed to deliver.
The Director of Nursing told inspectors the expectation had always been clear: licensed nurses were to follow physician orders, IV medication should have been administered, and PICC line care should have been provided. The goal, the DON said, was to clear the infection as soon as possible.
Three days passed without evidence that happened.
The facility's own policies, reviewed by inspectors during the survey, stated that all medications and treatments would be documented accurately and that physician orders, including treatment and procedure orders, were to be implemented. Both policies were undated. Neither appeared to have prevented the lapse.
What the inspection does not answer is what happened to Resident 97 as a result. The report notes the level of harm as minimal harm or potential for actual harm, a regulatory classification that covers a wide range, from a near-miss to something that caused real damage that inspectors could not fully measure. Whether the infection worsened during those three days, whether the PICC line clotted, whether the antibiotic course had to be extended or restarted, whether a physician was notified, none of that appears in the record.
LN 22 was the nurse who spotted the gaps. She reviewed the documentation and found nothing. She told inspectors what she found and what it meant. The inspection report does not identify which nurses were assigned to Resident 97 on April 1, 2, or 3, or whether any of them were asked to explain the missing entries.
Carmel Mountain Rehabilitation & Healthcare Center is located at 11895 Avenue of Industry in San Diego. The inspection was conducted on April 24, 2025, and the deficiency was cited at a scope and severity level reflecting few residents affected and minimal harm or potential for actual harm.
Resident 97 was trying to clear an infection. The drug to do it was ordered, the line to deliver it was in place, and for at least three days, nobody wrote down that any of it happened.
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 27, 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, identified in inspection records as Resident 97, was receiving Merrem, an intravenous antibiotic used to treat serious bacterial infections.
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.