Carmel Mountain Rehabilitation & Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to update and implement the care plan for one of three residents (Resident 1) reviewed for falls. As a result, Resident 1 continued to sustain additional falls and was placed at risk for injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate monitoring following a change in condition for one of three residents (Resident 1) reviewed for falls. As a result, Resident 1 had the potential to have injuries related to the fall to go unnoticed, and to receive delayed care from staff. According to the facility's admission Record, Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included repeated falls, displaced fractures of the fifth and sixth cervical vertebrae (bones that form the spinal column), and displaced intertrochanteric fracture of left femur (a broken hip). [...]

Inspectors wroteBased 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. These failures had the potential to spread bacteria within vulnerable residents of the subacute unit, and to staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had access to care and services for two of two sampled residents reviewed for Resident Rights (Resident 1 and Resident 2), when: 1. The facility did not provide Resident 1 condom catheters (can be used by men to collect urine) and he had to purchase/ order for himself.2. Resident 2 did not have access to television channels for activity. These failures had the potential not to meet Resident 1's needs and affect Resident 2's mental health that may affect their quality of life.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to implement a facility plan for a power outage and accurately report the unusual occurrence to the California Department of Public Health (CDPH). As a result, the facility was not prepared for a planned power outage, and 50 of 111 residents did not receive their medications in a timely manner. Cross reference:

Inspectors wrote1b. Resident 17 was admitted to the facility on [DATE] with diagnoses to include dependence on a ventilator (a machine used to support or replace the breathing of a person who is ill), per the facility admission Record. A record review was conducted. Per the 3/4/25 MDS, Resident 17 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS indicated Resident 17 required full staff assist for toileting, bathing, dressing, personal hygiene, and turning in bed. An interview was conducted with Resident 17 on 4/21/25 at 11:01 A.M. Resident 17 stated when she used her call light to get help, the CNAs come in to help her, At their convenience. Resident 17 stated she had anxiety, and waiting too long for help made her anxiety worse. An interview was conducted with the DON on 4/24/25 at 12:46 P.M. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper food sanitation procedures when expired food was identified in the kitchen refrigerators, and in the nursing unit refrigerator. These failures had the potential to cause foodborne illness to the residents who received food from the kitchen and/or nursing unit refrigerator.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility) deficient trends found by surveyors during the recertification survey concerning call light response and the lack of homelike environment for the residents. This failure had the potential for the facility to overlook trends in resident care that might have affected residents' health and quality of life. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility did not follow infection control practices when: 1) Staff did not don (put on) and doff (remove) Personal Protective Equipment (PPE- gown, gloves, mask) or perform hand hygiene when providing care to a resident on Enhanced Barrier Precautions (EBP, use of PPE when providing high contact resident care to reduce the spread of bacteria), and, 2) Two ice scoops were not stored in a sanitary manner. As a result, there was the potential for cross contamination, affecting the health of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers consistently for one of one sampled resident (Resident 24), reviewed for choices related to personal care. As a result, Resident 214's preferences and choices were not honored and respected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement individual care plans for two of five resident's (Resident 214 and Resident 220), reviewed for care plans. This failure resulted in Resident 214 experiencing pain, when a care plan was not developed for constipation and Resident 220's plan of care was not implemented as ordered by the physician, to wear bilateral foam boots (both feet), to protect and prevent future skin injuries to the heels.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 97), reviewed for closed record, when: 1. Staff failed to follow physician's order related to intravenous (IV, within a vein) antibiotics (anti-infective medications) therapy for Resident 97, and, 2. Consistently provide Resident 97's peripherally inserted central catheter (PICC, a long, thin tube inserted through a vein in the arm) care. These failures placed Resident 97 at risk for delayed healing and PICC line associated complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order related to pressure ulcer (a localized injury to the skin and underlying tissue caused by prolong pressure), treatment and prevention for one of four residents (Resident 43), reviewed for pressure ulcers. This failure had the potential for worsening or additional pressure ulcers to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision during toileting for a resident identified as high risk for falls. In addition a gait belt (a safety device used by caregivers to assist residents with mobility issues), was not utilized during transferring the resident from bed to a bedside commode for one of three residents (Resident 220), reviewed for accidents. These failures could potentially contributed to Resident 220 having an unwitnessed fall in the room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Bowel and Bladder protocol for two of two residents (Resident 214 and 104) reviewed for Bowel and Bladder when: 1. The constipation bowel regimen was not implemented after three days of no bowel movement for Resident 214; and, 2. The urine output (UO) was not consistently documented for Resident 104, who had a urinary catheter (a tube inserted into the bladder to aid in urine flow). This failure had the potential for increased and unnecessary pain for Resident 214, along with no consistent monitoring of urine output for Resident 104.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis (the process of cleaning the blood through a machine) access site was properly cared for one of one resident reviewed for dialysis (Resident 87). This deficient practice had the potential for Resident 87's dialysis access to clot.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 24 sampled residents (Resident 17) received: 1. A physician's explanation for renewal of a PRN (as needed) anti-anxiety medication, 2. Review and monitoring of the behaviors which required the use of an anti-anxiety medication, and, 3. A scheduled Gradual Dose Reduction (GDR, a required attempt to reduce dosage of a medication) for the anti-anxiety medication. These failures had the potential for Resident 17 to receive unnecessary medications, or more medication than necessary to treat anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document the correct extremity involved in their weekly wound evaluation summary for one of four residents (Resident 43), reviewed for wound care. This failure had the potential for confusing and misleading information in Resident 43's clinical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physicians' plan of care related to skin and wound treatments for three of three residents (Residents 1, 2, and 3) reviewed for Comprehensive Care Plans. This failure had the potential for Resident 1, 2, and 3's skin and wound injuries to worsen.

Inspectors wroteBased on observation, interview and record review, the facility fall evaluation tool did not accurately represent the fall risk status of three residents, (Residents 1, 2 and 3), sampled for admission fall risk evaluation. Per the Director of Nursing (DON), the fall evaluation tool did not allow nursing staff to include all medications and medical diagnoses that could increase fall risk, which resulted in artificially low fall risk scores. This failure had the potential to contribute to one or more actual falls for each sampled resident, and a right hip fracture (a break or crack in a bone) for resident 1.

Inspectors wroteBased on interview and record review, the facility failed to create an admission fall risk care plan for one resident, (Residents 1), sampled for baseline care plan. This failure had the potential outcome of contribution to two falls for Resident 1 who sustained a fracture (a break or crack in a bone) of her right hip.

Inspectors wroteBased on interview and record review, one resident (Resident 1) was served a food item inconsistent with the prescribed therapeutic diet. This failure had the potential to cause Resident 1 difficulty swallowing safely.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its COVID-19 mitigation plan when: 1. front desk staff did not request people who entered the facility to wear a mask during a COVID-19 outbreak (at least three confirmed positive cases within a seven day period). 2. Infection Preventionist (IP) 1 allowed a visitor into the COVID-19 isolation area without an n95 mask (a highly protective respiratory mask). 3. Floor staff did not stop unmasked visitors to ask them to wear a mask while inside the facility. 4. Licensed Nurse (LN) 1 had a mask under her chin when she entered a patient room. 5. A Certified Nursing Assistant (CNA) and a Receptionist were unmasked in a hallway. 6. All but two kitchen staff were unmasked in the kitchen during lunch preparation. These failures had the potential to infect vulnerable residents with COVID-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision for one resident, Resident 3, sampled for falls. This failure had the actual outcome of Resident 3 suffering two fractured ribs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff followed policy and procedure when: 1) opened food items were not labeled and dated properly 2) opened food item was not discarded by use by date and 3) a. knife had food debris on it and b. a kitchen staff did not change gloves after washing a used blender during food preparation. As a result, there was a potential for foodborne illness (illness caused by food contaminated by microorganisms and toxin) and cross-contamination (physical transfer of harmful bacteria).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff adhered to proper infection control practices when : 1. a resident's urinary catheter (a tube inserted into the bladder to aide in urine flow) bag and dignity bag (a bag used to cover and conceal contents inside), were laying on the floor on 1 of two residents (Resident 81). 2. the staff did not perform hand hygiene (HH- washing hands with soap and water or use of hand sanitizer to kill microorganisms a) after exit from resident's room and b) before entry to residents' room. 3. the staff did not perform HH in between glove changes a) during wound care and b) after glove removal and before putting on new glove. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity was maintained for one out of six residents (Resident 320) when Resident 320's urine collection bag was not concealed from public view. This failure had the potential to negatively affect the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their policies on medication self-administration (resident takes medication without staff assistance) were implemented for one of one sampled resident (Resident 101) when the facility did not determine the resident was clinically appropriate and safe to self-administer a medication. This failure had the potential to result in unsafe medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to address resident's needs for one of 29 sampled residents (Resident 316) when the resident's call light (device used to call staff's assistance) was not placed within reach. This failure had the potential for Resident 316's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician Order for Life-Sustaining Treatment (POLST- a written medical order from a healthcare provider based on patient preferences on the type of medical treatment they want to receive during serious illness) was signed by the physician in a timely manner for one of two sampled residents reviewed for advance directives (Resident 62). As a result, the POLST was not valid for a patient who wished to be on Do Not Attempt Resuscitation (DNR- allow natural death) in case of a serious illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff protected the confidential information of two of 29 sampled residents (Resident 216 and Resident 215) when the computer monitors were left open and unattended. This failure had the potential for the residents' personal and confidential medical information to be visible to unauthorized persons.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a homelike environment was provided for two of 29 sampled residents (Resident 50 and Resident 216) when the bedrails' black foam was ripped, torn and in disrepair condition. This failure had the potential to negatively impact the resident's comfort, well-being, and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed for: 1) psychotropic (drugs that affect mood, behavior, thoughts and perception) medications and 2) code status (an instruction on what the medical team should do if a resident had a cardiac or respiratory arrest) for two of two sampled residents (Resident 6 and Resident 62): As a result, there was a potential for 1) Resident 6's psychotropic medications were not managed appropriately and 2) Resident 62's code status was not followed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal care was provided for one of three sampled residents (Resident 319) when Resident 319 had white, crusty substance on the inner side of her eyes. This failure had the potential to result in poor personal hygiene and decreased psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure staff followed physician's orders when : Resident on daily weight was not weighed daily on 1 of 2 residents (Resident 41) These failures had the potential to result in decreased physical and psychosocial well being for the residents. Resident 41 was admitted to the facility on [DATE] with diagnoses which included Morbid (severe) obesity due to excess calories and Chronic Kidney disease Stage 3 per facility's admission Record. On 5/7/24 at 10:34 A.M. a concurrent observation and interview with Resident 41 was conducted in Resident 41's room. Resident 41 was on a wheelchair waiting for his lunch. Resident 41 stated the facility was supposed to weigh him daily to monitor his weight. Resident 41 stated the facility sometimes were not weighing him everyday. On 5/7/24 at 10:49 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Restorative Nursing Assistance (RNA- care to improve or maintain functional ability) was conducted per the physician's order for one of two sampled residents reviewed for limited range of motion (Resident 6). As a result, there was a potential for development of further contractures (chronic loss of joint mobility) for Resident 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure tube feeding (TF-nutrition in liquid form through a tube) was labeled appropriately per the facility's policy for two of three residents reviewed for TF (Resident 6 and Resident 106). As a result, there was a potential the residents may not receive the adequate amount of TF per physician order.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff was able to verbalize the accurate steps in administering a tube feeding (TF - nutrition in liquid form through a tube) for one of three residents (Resident 20). This failure had the potential to negatively affect Resident 20's health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medication was administered accurately to one of 29 sampled residents (Resident 17) when the Licensed Nurse (LN) administered a medication without properly identifying the resident. This failure had the potential for residents to be administered with wrong medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all medications were locked for one of seven medication carts (Medication Cart # 1). This failure had the potential for Medication Cart # 1 to be accessed by unauthorized personnel.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fire extinguishers in the kitchen were inspected in a timely manner. As a result, there was a potential the fire extinguishers were not safe to be used.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address resident's needs for one of three sampled residents (Resident 7) when Resident 7's call light (device to call staff for help) was not placed within reach. Review of Resident 7's admission diagnoses dated 11/09/21 included gout (severe pain in the joints) and hypertension (increased blood pressure). An observation and interview was conducted on 7/25/23 at 12:45 P.M. inside Resident 7's room. Resident 7 was observed to be frustrated that he was not able to locate his call light device. Resident 7's call light was observed wrapped around his side rail. Resident 7 stated he could not reach his call light. A concurrent observation and interview was conducted on 7/25/23 at 12:46 P.M. with certified nursing assistant 1 (CNA 1) inside Resident 7's room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a patient centered care plan related to PTSD (Post-traumatic stress disorder - a disorder that may occur in people who have experienced or witnessed a traumatic event) for one of 21 residents (Resident 72) reviewed for care plans. This failure had the potential risk of not providing appropriate, consistent, and individualized care to Resident 72.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure one of eight residents (Resident 72) reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), received care and services in accordance with professional standards when Resident 72's PTSD (Post-traumatic stress disorder - a disorder that may occur in people who have experienced or witnessed a traumatic event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify Resident 72's possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience).

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely administer prescriber's ordered medications to one of five sampled residents (Resident 264). This failure had the potential to cause delay and compromise resident's medical health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 3 sampled residents (Resident 407 and Resident 25) reviewed for psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication were free from unnecessary use of medication when: 1. Resident 407 did not have behavior monitoring for the four psychotropic medications (psychoactive drugs taken to exert an effect on the chemical makeup of the brain and nervous system). 2. Resident 25's Ativan (medication to treat anxiety, which act on the brain and nerves) ordered to be given as needed, did not have a stop date. This failure had the potential for healthcare providers to not determine the effectiveness of Resident 407's psychotropic medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 6.9% when two medication errors occurred out of 29 opportunities during medication administration for one of five residents (Resident 9). These failures resulted in the resident not receiving the full therapeutic effects of the medication.

Inspectors wroteThe facility failed to discard four expired cans of food of 20 cans reviewed. This failure put residents at risk of consuming spoiled food.