Carmel Mountain Rehab: Wrong Heel Documented in Wound Care - CA
The resident was a woman admitted to the facility with cellulitis, a bacterial infection that had spread into the skin and underlying tissue of her lower legs, along with sepsis, a condition in which the body's response to that infection had turned dangerous. She told an inspector she got a wound on her left heel after her legs swelled from the infection. When the inspector visited her room on the morning of April 21, she was sitting up in bed wearing a padded green boot on her left foot, both heels resting directly on the mattress.
Her physician had written an order on April 3 spelling out exactly what to do: cleanse the left heel wound with normal saline, pat it dry, apply Santyl ointment to remove damaged tissue, cover it with xerofoam gauze and a foam dressing, every day shift. Left heel. The order said it twice.
The facility's own weekly wound evaluations, completed on March 17 and again on March 31, recorded the wound as being on the right heel.
Two weeks of documentation. Wrong side, both times.
When the wound treatment nurse sat down with an inspector on April 23 and reviewed those two evaluations, she said they were incorrect. The wound was on the left heel, not the right. She acknowledged the inaccurate documentation could confuse anyone reading the chart and would provide inaccurate information.
The Director of Nursing, interviewed the following morning, said weekly wound evaluations should be accurate and concise. She said documenting the wrong extremity could confuse the reader. She said she expected the location and description to be correct.
Neither offered an explanation for how the error happened twice, across two separate evaluations, two weeks apart.
The practical stakes of a documentation error like this one are easy to understate. A wound on a resident with cellulitis and a history of sepsis is not a routine scrape. Cellulitis can spread. Tissue can die. When a nurse, a physician, or a covering provider picks up a chart and reads that the wound is on the right heel, and then looks at the left, the gap between the record and the patient is the gap between knowing what's happening and not knowing. Wound size, wound progress, wound response to treatment — all of it is anchored to a location. Get the location wrong and the entire record of that wound's history becomes unreliable.
The facility's own documentation policy, though undated, states plainly that all wounds and treatments will be accurately documented in the resident's record. The wound treatment nurse and the Director of Nursing both confirmed what the policy required. What neither could explain was why it didn't happen.
Federal inspectors classified the violation as having the potential for actual harm, with few residents affected. It was the only deficiency cited in the inspection, completed April 24.
The resident, meanwhile, sat in her room with a green boot on her left foot, both heels on the mattress, describing how her legs had swelled from the infection that brought her there. Her chart said the wound was somewhere it wasn't.
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 30, 2026 · Our methodology
CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER in SAN DIEGO, CA was cited for violations during a health inspection on April 24, 2025.
She told an inspector she got a wound on her left heel after her legs swelled from the infection.
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.