Carmel Mountain Rehab: Missed Wound Treatments - CA
The April 2025 inspection found the facility had failed to carry out physician-ordered wound care for at least one resident, identified in inspection records as Resident 43. The treatment nurse reviewed the resident's April 2025 treatment administration record during an interview with inspectors on April 23 and found no documentation of a wound treatment on April 5. She said the gap meant the treatment was skipped, and that missing a treatment "could complicate the healing of a wound."
She also acknowledged that foam boots, which keep pressure off the heels to prevent new wounds from forming and protect existing ones from getting worse, had been ordered for Resident 43 by a physician. They were not applied.
The wound treatment nurse described her weekend routine to inspectors: she handled treatments herself, and when she got too busy, she asked the medication nurse to help. Whether that handoff happened on April 5, whether anyone followed through, the record offered no answer. There was no documentation at all.
The Director of Nursing, interviewed the following morning, said she expected all wound treatments to be performed according to physician orders. She said a missed treatment "could deteriorate and become infected." She confirmed that both foam boots should have been applied to Resident 43, as the physician had ordered.
The facility's own wound care policy states that treatments will be documented accurately and in a timely manner. Its policy on physician orders states the facility will accurately transcribe and implement orders in accordance with each resident's plan of care.
Neither happened here.
Wound care lapses in nursing homes carry real consequences. Pressure wounds, particularly on the heels and feet of residents with limited mobility, can progress rapidly when treatment is inconsistent. A stage two wound left untreated can deepen. An infected wound in an elderly resident can become a systemic crisis. Foam boots exist precisely because the heels are especially vulnerable, bony and poorly padded, and because residents who cannot reposition themselves depend entirely on staff to protect them.
The Director of Staff Development, also interviewed during the inspection, told inspectors that missed wound treatments were a problem because wounds could worsen or become infected. She said foam boots should be worn to prevent additional wounds and to protect any existing ones.
Three separate staff members, the treatment nurse, the Director of Staff Development, and the Director of Nursing, all told inspectors the same thing in their own words: this matters, this causes harm, this should not happen. None of them disputed what the record showed.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, with few residents affected. CMS assigns that designation when a problem has not yet caused serious injury but carries real risk of doing so. It is not a finding that nothing went wrong. It is a finding that something went wrong before the damage became undeniable.
Carmel Mountain Rehabilitation & Healthcare Center operates at 11895 Avenue of Industry in San Diego. The inspection was completed April 24, 2025.
Resident 43's wound treatment record for April shows a blank where April 5 should be. The foam boots remained off. Whether the wound healed, worsened, or became infected, the inspection report does not say.
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 28, 2026 · Our methodology
CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER in SAN DIEGO, CA was cited for violations during a health inspection on April 24, 2025.
Whether that handoff happened on April 5, whether anyone followed through, the record offered no answer.
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.