Carmel Mountain Rehabilitation & Healthcare Center
CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER in SAN DIEGO, CA — inspection on April 24, 2025.
Found 15 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
According to the facility's policy, titled Accommodation of Needs, undated, .Examples of Accommodation of Needs but is not limited to the following: .Call lights .
According to the facility's policy titled Incontinence Care, undated, .this facility will provide incontinence care for those residents requiring assistance with bladder and/or bowel incontinence.
Staff providing incontinence care will do so while maintaining dignity of the resident .
According to the facility's policy, titled Call Light/Bell, undated, .1.
Answer light/bell within a reasonable time . 2a. On 4/21/25 at 8:06 A.M., an observation was conducted in the hallway on one of the facility's units. A cart containing breakfast trays for residents on the unit was brought out by kitchen staff and left in the hallway.
On 4/21/25 at 8:39 A.M., an observation was conducted at the meal cart. CNA 31 and CNA 32 began passing out the meal trays to approximately 25 residents on the unit.
On 4/21/25 at 3:25 P.M., an interview was conducted with Resident 317. Resident 317 stated, This morning I just ate my cereal. I didn't eat the eggs because they were ice cold.
The trays are always cold. 2b.
During a Resident Council Meeting conducted on 4/22/25 at 10:20 A.M., CR 1 stated, .some days it takes a while for staff to bring the meal trays out .A.M. shift has so much to do that they can't get the food out on time . CR 1 stated his meal tray was often cold when it was delivered by staff.
On 4/24/25 at 1:45 P.M., an interview was conducted with the DON.
The DON stated it was her expectation staff distribute meal trays to residents as soon as the cart was delivered to the unit.
The DON stated, They should have immediately passed out the trays, or at least communicated that the carts were out. We don't want the residents to have cold food.
During a review of an undated policy titled Resident's Rights, Accommodation of Needs, the policy indicated, .It is the policy of this facility to provide accommodation of reasonable needs to the residents while in the facility, Procedures: Staff will review resident's preference and accommodate their needs .
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Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
indicated, Policy: It is the policy of this facility that residents are given the appropriate .services
555326 04/24/2025
Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
maintenance log, then the maintenance workers would review the log and make the repairs.
The
environment.
On 4/23/25 at 11 A.M. a concurrent observation of resident rooms, and interview with the Director of Maintenance (DM) and Administrator (ADM 2) was conducted.
All resident rooms with concerns were viewed.
The DM stated since fans were electrical, his department was responsible for cleaning the fans.
The DM stated he rounded each day but relied on staff to communicate items that needed repair.
The DM stated staff can either write down the items in the maintenance log, which he checked daily, or call him directly.
The DM stated he did not recall anyone from the nursing unit calling him in regards to the fans or the damage in the rooms.
The DM stated it did not give a good impression to residents or visitors if the rooms and equipment were dirty or damaged. ADM 2 stated the nursing unit was starting a rounding program to identify the problem areas.
On 4/24/25 at 12:54 P.M., an interview was conducted with the Director of Nursing (DON).
The DON stated all furniture in the resident rooms should be intact, and all fans clean.
The DON stated it was her expectation that all staff going into rooms would report items needing repair and inform the appropriate staff, including the NM.
Per the DON, We try to provide a homelike environment for all residents. We missed some things because the DM is new, but that is no excuse.
Per a facility policy, revised May 2007 and titled Housekeeping, It is the policy of this facility to provide a clean, comfortable, homelike and sanitary living area .
Per an undated facility policy, titled Resident Rights, .Safe Environment.
You have a right to a safe, clean, comfortable and homelike environment .
555326 04/24/2025
Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
According to the facility's policy, titled Fall Management System, undated, .2.
Residents with Fall Risk Assessments score of 11-16 or above are considered high risk and will have an individualized care plan develop[ed that included measurable objective and timeframe's.
The care plan interventions will be developed to prevent falls and will consider the elements of assessment that put the resident at risk .
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Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
missed entries for medication administration of Merrem for Resident 97 on 4/2/25 and 4/3/25 at 6
LN 22 stated there were missed PICC line care for Resident 97 on 4/1/25 and 4/2/25 and 4/3/25. LN
documentation from other LNs if the medications were administered per the physician's order and the PICC line care was rendered. LN 22 stated, If it was not documented, it was not given.
On 4/24/25 at 10:38 A.M., an interview was conducted with the Director of Nursing (DON).
The DON stated the expectation was for the LNs to follow the physician's orders, IV medication should have been administered and PICC line care should have been provided for Resident 97 to clear the infection as soon as possible.
A review of the facility's undated policy titled, Nursing Services, Physician Orders, indicated, .It is the policy of this facility to .implement orders in addition to medication orders (treatment, procedures) .
A review of the facility's undated policy titled, Documentation, Charting and Documentation, indicated, The resident's clinical record is a concise account of treatment, care .and progress of the resident's condition .Rules for Charting .5.
All medications and treatments will be documented accurately .
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Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
According to the facility's policy, titled Pressure Ulcer Management, undated, .7.
Treatments will be documented accurately and in a timely manner .
According to the facility's policy, titled Physician Orders, undated, .It is the policy of this facility to accurately transcribe and implement orders .in accordance with the resident's plan of care .
555326 04/24/2025
Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
According to the facility's policy, title Gait Belt, undated, .2.
Gait belts must be used when transferring and ambulating residents .
555326 04/24/2025
Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
urinary catheter because he underwent back surgery.
On 4/23/25 at 8:47 A.M., an observation and an interview of Resident 104 was conducted in his room. Resident 104 was sitting up in bed and a urinary catheter was attached to the bed rails. Resident 104 stated he retained fluids and experienced a distended bladder because he could not urinate properly. Resident 104 stated the staff emptied the urinary catheter, collected the urine into a urinal and discarded the urine to the toilet bowl.
On 4/23/25, a review of Resident 104's clinical record was conducted. Resident 104's physician's order and care plan (detailed plan with information about a patient's treatment, goal, and interventions) dated 3/6/25 indicated to measure, monitor and document Resident 104's urine output (UO) for 30 days.
A review of Resident 104's record of urine output for March and April 2025 was conducted.
The record had missed entries of UO for Resident 104 on the following dates and shifts: 3/6, 3/14, 3/18, 3/19 - nocturnal shifts (from 11 P.M to 7 A.M.) 3/8, 3/18, 3/19, 3/20, 3/31, 4/2 through 4/5 - morning shifts (7 A.M to 3 P.M.) 3/7, 3/8, 3/11, 3/13, 3/20, 4/1, 4/2 through 4/4 - afternoon shifts (3 P.M to 11 P.M.) 3/16, 3/17, 3/22 through 3/30 - no entries for all shifts.
On 4/23/25 at 11:28 A.M., a joint review of Resident 104's clinical record and an interview was conducted with LN 21. LN 21 stated Resident 104 retained urine and had a fluid restriction of two liters per day. LN 21 stated it was important to monitor Resident 104's UO to ensure Resident 104 was not retaining fluids to prevent him from getting a distended bladder. LN 21 stated Resident 104's UO should have been monitored and documented, but it had not been. LN 21 stated the CNAs emptied and tracked Resident 104's UO and documented in a log. LN 21 stated the staff did not consistently monitor and document Resident 104's UO per physician's order and per facility's policy.
On 4/24/25 at 10:38 A.M., an interview was conducted with the DON.
The DON stated the expectation was for the licensed staff to monitor Resident 104's UO to ensure Resident 104 did not have bladder distention, and for Resident 104's comfort.
A review of the facility's undated policy titled, Intake and Output Documentation, indicated, It is the policy of this facility that fluid intake and output shall be recorded for each resident with an indwelling .catheter or as prescribed by the physician .Procedures .2.
The .output information is to be recorded at the end of each shift by a Licensed Nurse .
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Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
policy of this facility to provide standards in the care of the residents on renal dialysis and the care of
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Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
every resident's right to be free from Psychotropic drugs.
The facility shall ensure that: .2.
Residents
renewed unless the prescribing practitioner evaluates the resident for the appropriateness of the
need/justification of the medication and possible Gradual Dose Reduction .
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Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
serve food in accordance with professional standards.
sanitation procedures when expired food was identified in the kitchen refrigerators, and in the nursing
These failures had the potential to cause foodborne illness to the residents who received food from the kitchen and/or nursing unit refrigerator.
Findings
A concurrent kitchen tour and interview with the Dietary Services Supervisor (DSS) was conducted on 4/21/25 at 8:23 A.M. In the walk-in refrigerator, a bag containing approximately eight ounces of shredded parmesan cheese was found to have a Use By Date of 4/17/25. A reach-in refrigerator contained six small plastic containers of peaches, with a Use By Date of 4/20/25.
The DSS stated both foods should have been disposed of on the Use By Date.
The DSS stated expired food had the potential to cause foodborne illness to the residents.
A concurrent observation of nursing unit refrigerators and an interview with a Nurse Manager (NM 1) was conducted on 4/24/25 at 10:45 A.M.
Three containers of expired yogurt was identified. NM 1 stated the yogurt should have been thrown away, and it was her job to check the refrigerator for dates.
An interview was conducted with the Registered Dietitian (RD) on 4/24/25 at 11 A.M.
The RD stated residents were allowed to bring food from home, and it was the staff members' responsibility to label and date the foods.
The RD stated the nursing staff, as well as kitchen staff, was responsible for ensuring foods were labeled and dated, and also to dispose of items by their expiration date.
The RD stated it was important to monitor the refrigerated foods for expiration date to prevent foodborne illness to the residents.
Per a facility policy, dated 2023 and titled Labeling and Dating of Foods, Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety .The Use By date will be the absolute date in which the food must be consumed or discarded by the facility .Once daily, the PM [NAME] and/or PM Diet Aide will be responsible to inspect the refrigerators and discard perishable foods .in order to ensure food safety.
555326 04/24/2025
Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
According to the physician's order, dated 4/3/25, cleanse left heel wound with normal saline, pat dry, apply Santyl ointment (used to remove damaged tissue from chronic skin ulcers), followed by xerofoam (a type of petrolatum-based gauze dressing used in wound care), cover with foam dressing every day shift.
According to the facility's weekly wound evaluations conducted on 3/17/25 and 3/31/25, the wound was identified and measured as being on the right heel, instead of the left heel.
An interview and record review was conducted with the wound Treatment Nurse (Tx LN) on 4/23/25 at 11:21 A.M.
The Tx LN reviewed Resident 43's weekly wound evaluations for 3/17/25 and 3/31/25, and stated they were incorrect because the wound was on the left heel, not the right.
The Tx LN stated the inaccurate documentation could confuse the reader and provide inaccurate information.
An interview was conducted with the Director of Nursing (DON) on 4/24/25 at 9:11 A.M.
The DON stated weekly wound evaluations should be accurate and concise.
The DON stated documenting the wrong extremity could confuse the reader and she expected the location and description to be correct.
According to the facility's policy, titled Documentation, undated, .6.
All wounds and treatments will be accurately documented in the resident's record .
During the recertification survey, deficient trends in call light response and the lack of homelike environment were identified.
The DON stated that call light response was an ongoing project, but when asked about the root cause of the call light issues, the facility was unable to identify one.
The DON stated identifying the root cause of the call light issues was challenging.
The DON stated it was important to work towards a reduction in complaints related to call light response.
Regarding the lack of homelike environment, ADM 1 stated there had been a budget approved for residents' room improvements, but this had not been included in the QAA Committee and/or included in the QAPI plan.
Review of the facility policy titled Quality Assurance and Performance Improvement dated January 2025 indicated .The purpose of the QAPI Plan and processes is to continually assess the facility's performance in all service areas, so that concerns and processes achieve the delivery of person-centered care, and which maximizes the individual's highest physical, mental, and social well-being .
555326 04/24/2025
Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
According to the facility's policy titled Infection control, undated, .1.
Standard Precautions are infection prevention practices that apply to the care of all residents .e.
Environmental cleaning and disinfection .
555326 04/24/2025
Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
During the recertification survey, deficient trends in call light response and the lack of homelike environment were identified.
The DON stated that call light response was an ongoing project, but when asked about the root cause of the call light issues, the facility was unable to identify one.
The DON stated identifying the root cause of the call light issues was challenging.
The DON stated it was important to work towards a reduction in complaints related to call light response.
Regarding the lack of homelike environment, ADM 1 stated there had been a budget approved for residents' room improvements, but this had not been included in the QAA Committee and/or included in the QAPI plan.
Review of the facility policy titled Quality Assurance and Performance Improvement dated January 2025 indicated .The purpose of the QAPI Plan and processes is to continually assess the facility's performance in all service areas, so that concerns and processes achieve the delivery of person-centered care, and which maximizes the individual's highest physical, mental, and social well-being .
555326
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555326 B.
Wing 04/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.