Carmel Mountain Rehabilitation & Healthcare Center

In the surveyor’s words

From the most serious findings on record at Carmel Mountain Rehabilitation & Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 15, 2026

  Based on observation, interview, and document review, the facility failed to implement fall preventative measures recommended by the Fall IDT (Interdisciplinary Team- a group of individuals with different areas of expertise) for one of three residents (1) who was assessed as a high fall risk with a history of multiple falls. As a result, Resident 1 experienced additional falls on 3/2/26 which resulted in hospitalization and surgery for a fractured (broken) hip. Findings:A review of the undated admission Record indicated, Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included repeated falls prior to admission at the facility and displaced fractures of the fifth and sixth cervical vertebrae (bones that form the spinal column), and displaced… […]

• No harm, potential for more than minimal, patternF880Jan 22, 2026

  Based on observation, interview, and record review, the facility failed to adhere to infection prevention protocols in 3 out of 3 rooms on Enhanced Barrier Precautions (an infection control measure requiring staff to wear gowns and gloves during high-contact resident care) when: A foley catheter bag was observed on the floor.A staff member was observed handling soiled linen and trash in the hallway.A staff member did not perform hand hygiene before entering and exiting a room of a resident on Enhanced Barrier Precaution. […]

• No harm, potential for more than minimal, patternF755Sep 4, 2025

  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. […]

• No harm, potential for more than minimal, patternF558Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to meet resident needs in a timely manner for four of four residents (Residents 214, 17, 104, and 317), reviewed for accommodation of needs and one confidential resident (CR 1) when: 1. Resident 214, 17 and 104 experienced a delay for staff to provide personal care; and, 2. Resident 317 and CR 1 did not receive their meals in a timely manner. These failures had the potential for residents to feel not dignified and not valued. Findings: 1a. […]

• No harm, potential for more than minimal, patternF584Apr 24, 2025

  Based on observation and interview, the facility failed to ensure a clean, safe and comfortable homelike environment when: 1. An observation of 11 of 24 resident areas in one nursing unit had dirty wall-mounted fans in their rooms, and 2. An observation of 13 of 24 resident areas in one nursing unit had broken furniture, holes in the wall, and/or scraped paint areas in their rooms. These failures had the potential to negatively impact the residents' health and well-being. Findings: On 4/21/25 starting at 8 A.M., observations of all resident rooms on one nursing unit was conducted. Nine of 11 residents were unable to speak and had no visitors present. […]