Carmel Mountain Rehabilitation & Healthcare Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

(MDS, a federally mandated resident assessment tool), dated 9/11/25, Resident 2 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 13/15, which indicated Resident 2's cognition was intact. On 9/16/25 at 2:35 P.M., an observation of Resident 2 in his room and an interview was conducted with Resident 2 and a family member (FM) at bedside. Resident 2 laid in bed and the television (TV) was off.

Resident 2's FM stated the TV did not work properly since it only had four channels and one of which was a foreign language. Resident 2's FM stated Resident 2 had been in his room for 12 days without entertainment. Resident 2's FM stated the issue was brought up and nothing had been done. Resident 2's FM stated Resident 2 did not want to join the group activities because it was loud. Resident 2's FM took the remote control from the bed and attempted to look for channels. There were four channels streamed on the TV, one in foreign language, one was news, one was classic show, and one was shopping channel.

Resident 2's FM turned off the TV. Resident 2's FM stated Resident 2 just stayed in bed and had nothing to do. Resident 2 then closed his eyes. On 9/16/25 at 3:05 P.M., a joint observation of Resident 2's TV channels and an interview was conducted with the Maintenance Director (MaD). The MaD stated the facility was in the process of changing providers for the TV. The MaD stated sometimes the TV got high channels and sometimes got the low channels. The MaD stated the TV channels were not consistent, and some residents' TV only had four channels. The MaD stated that it was not a good experience for the residents having no entertainment. On 9/16/25 at 3:54 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 2 was very alert and oriented. CNA 2 stated Resident 2 was recently admitted to the facility. CNA 2 stated the facility had issues with the TV channels for two weeks, some channels were not working. CNA 2 stated some residents did not like to attend activity because some residents were yelling. CNA 2 stated the TV was a form of activity for some residents and if the residents could not access other channels, it was frustrating for them. CNA 2 stated, They could feel bored. On 9/16/25 at 4:56 P.M., a joint interview was conducted with the Director of Staff Development (DSD) and the Director of Nursing (DON). The DSD stated Resident 1 was very alert and oriented. The DON stated the expectation was for the facility to accommodate the residents' needs. The DON stated, We will make sure

the TV will be fixed soon to accommodate his needs. A review of the facility's undated policy titled Resident Rights was conducted. The policy did not indicate accommodation of residents' rights and needs.

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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

09/16/2025

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

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

observation, interviews and record review, the facility failed to ensure safe and sanitary measures were met when a used urinal was on top of a resident's bedside table with food and cleaning supplies (Resident 2), for one of four residents reviewed for infection control. This failure had the potential for contamination of food and cleaning supplies and spread of infection to Resident 2 and his visitors.Findings: Resident 2 was admitted to the facility on [DATE REDACTED], per the facility's admission Record. Resident 2's minimum data set (MDS,

a federally mandated resident assessment tool), dated 9/11/25, Resident 2 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 13/15, which indicated Resident 2's cognition was intact. On 9/16/25 at 2:35 P.M., an observation of Resident 2 in his room and an interview was conducted with Resident 2 and

a family member (FM) at bedside. Resident 2 laid in bed and a bedside table was on his right side of the bed. On top of the bedside table was a used urinal with some drops of urine at the handle and at the bottom, a plastic bag of chocolate candies and cookies, and a roll of paper towel. Resident 2's FM stated

He used the urinal, they don't rinse it and they put in the table. That is where he eats because he prefers to eat here. Look there is the urinal with urine in the handle. Is not that an infection control issues? On 9/16/25 at 2:53 P.M., a joint observation of Resident 2's bedside table and an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated the used urinal should not be on top of the table for infection control. On 9/16/25 at 4:56 P.M., a joint interview with the Director of Staff Development (DSD) and the Director of Nursing (DON) was conducted. The DON stated the urinal should not be on the bedside table due to possible cross contamination for infection control. A review of the facility's policy titled Infection Control, revised 6/2025, indicated, It is the policy of this facility to implement infection control measures to prevent

the spread of communicable diseases and conditions.Procedure, 1. Standard Precautions are infection prevention practices that apply to the care of all residents.they are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents.

Standard Precautions include: Environmental cleaning and disinfection.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet