Carmel Mountain Rehabilitation & Healthcare Center
CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER in SAN DIEGO, CA — inspection on September 4, 2025.
Found 3 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 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.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
555326 09/04/2025
Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
services of a licensed pharmacist.
interview and record review, the facility failed to provide medications on time to 50 of 113 residents
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] 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].
555326 09/04/2025
Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128
this facility, that an unusual occurrence will be reported accurately and completely.
Frequently Asked Questions
More Reports
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.