Carmel Mountain Rehabilitation & Healthcare Center

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to ensure temperature was addressed and notified physician for one of two residents in a timely manner. These failures resulted in a delay of assessment and treatment for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE REDACTED], according to the facility admission Record. On 9/4/25 at 2:57 P.M., a concurrent interview and record review were conducted with the Director of Staff Development (DSD) and Licensed Nurse (LN) 1. LN 1 stated normal body temperature within 97 to 99 degrees Fahrenheit (F). According to the History and Physical Examination (H&P) by the physician on 12/10/24 and with diagnoses to include hypothermia (body drops below 95 degrees Fahrenheit (F). According to the facility change of condition evaluation dated 12/14/24 at 12 P.M., .Resident was noted to have low temperature @ 9.30am[sic] w/ readings at 92 and was rechecked at around 11am with readings at 90.2, resident was noted shivering and skin is cold. According to physician orders dated 12/14/24 at 11:59 A.M., transfer to hospital due to hypothermia. During this interview and

record review, LN 1 started receiving a report from a Certified Nurse Assistant (CNA) on 12/14/24 around 9:30 A.M. Resident 1's temperature was 92 F. LN 1 stated she was busy during that time and asked the CNA to take Resident 1's temperature. LN 1 stated around 11:49 A.M., Resident 1's temperature was 90.2 F. LN 1 stated she started a change of condition and informed the physician around 12 P.M. and Resident 1 was transferred to the emergency room via 911. LN 1 stated she should have assessed Resident 1 temperature right away. On 9/4/25 at 5:20 P.M., a concurrent interview and record review were conducted with LN 2. LN 2 stated she was approached by resident 1'a family member to check Resident 1's temperature. LN 2 stated this was about lunch time around 12 P.M. LN 2 stated Resident 1 was sitting in his room and a blanket wrapped around him. LN 2 stated Resident 1's low temperature should be addressed and notify the physician right away. On 9/4/25 at 5:42 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated she should notify the physician right away because Resident 1's hypothermia was a medical emergency. The DON stated Resident 1's temperature of 92 F was not normal.

According to the facility policy entitled Section: Care and Treatment Subject: Change of Condition Reporting, revised date 6/2013, indicated. all changes in resident condition swill be communicated to the physician.1. All symptoms and unusual sings will be communicated to the physician promptly.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Carmel Mountain Rehabilitation & Healthcare Center

11895 Avenue of Industry San Diego, CA 92128

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to provide medications on time to 50 of 113 residents during a planned power outage.This failure had the potential to affect the health and well-being of the residents.Findings:A consumer complaint was filed with the California Department of Public Health alleging that on 8/10/25, Resident 1 had not received medications as prescribed.An interview was conducted with

the Assistant Director of Nursing (ADON) on 8/11/25 at 1:50 P.M. The ADON stated the facility had experienced a planned power outage on 8/10/25, and nursing staff was unable to use the electronic Medication Administration Record (eMAR) to provide medications to all residents. The ADON stated 50 of

the 113 residents who resided in the facility on 8/10/25 received their scheduled morning medications after

the power came back on, approximately 10 A.M. The ADON stated she had spoken to Resident 1's family members, who wanted to remove the resident from the facility due to the medication problems.An interview was conducted with Licensed Nurse (LN) 1 on 8/11/25 at 2:15 P.M. LN 1 stated she was assigned to Resident 1 on 8/10/25, and had provided her medications once the power was on. LN 1 stated the medications were scheduled for 9 A.M., which meant they had to be administered between 8 A.M. and 10 A.M. to be considered on time. LN 1 stated Resident 1's medications were given late, at approximately 11 A.M. LN 1 stated, It is important to give certain medications at the right time, we didn't do that. There could be a risk to the resident's health.A record review was conducted on 9/4/25.Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses to include Parkinson's Disease (a movement disorder of the nervous system that worsens over time), per the admission Record.Resident 1 was prescribed the following medications for 9 A.M.:Thiamine (a vitamin), administered at 12:26 P.M.Vitamin D3, administered at 12:26 P.M.Rivaroxaban (a medication to prevent blood clots), administered at 1:08 P.M.Calcium (a mineral), administered at 12:26 P.M.Resident 1 was prescribed the following medications for 11 A.M.:Rytary (a medication for Parkinsons Disease), administered at 12:15 P.M.An interview was conducted with the Director of Nursing (DON) on 9/4/25. Per the DON, it was important to give medications on time, especially medications like Rytary for Parkinsons Disease. The DON stated the facility had not given any of Resident 1's medications within the allowed timeframe. Per the DON, this could result in the symptoms of Parkinsons Disease worsening.Per a facility policy, dated 11/20/24 and titled Medication Administration and Storage, .Review and verify MD orders and follow 6 Rights of Medication Administration [right patient, right medication, right use, right dose, right time, right route].

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Carmel Mountain Rehabilitation & Healthcare Center

11895 Avenue of Industry San Diego, CA 92128

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER in SAN DIEGO, CA for a deficiency under regulatory tag F-F0835 during a complaint investigation conducted on 2025-09-04.

Category: Administration Deficiencies

The facility was found deficient in the following area: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.