Carmel Hills Care Center
23795 W. R. Holman Highway, Monterey, CA 93940
Carmel Hills Care Center is a nursing home in Monterey, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (831) 624-1875
- Last standard health inspection
- April 17, 2026 (6 months ago)
- Certified beds
- 99
- Residents per day, on average
- 94.7
- Ownership type
- For profit - Corporation
- Legal business name
- Pater Dignitas INC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the California average (39 vs 50).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of June 24, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 2 of 5.
19 citations
Health inspection on April 17, 2026
CMS lists this as a standard inspection.
Citation F0732. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on May 7, 2026.
Citation F0801. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
CMS lists it as corrected on May 4, 2026.
CMS has cited this home for F0801 2 times since 2022.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 7, 2026.
CMS has cited this home for F0812 3 times since 2022.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on May 7, 2026.
Citation F0578. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on May 7, 2026.
Citation F0605. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on May 7, 2026.
Citation F0688. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS lists it as corrected on May 7, 2026.
Citation F0698. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on May 7, 2026.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 7, 2026.
CMS has cited this home for F0755 2 times since 2022.
Citation F0757. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on May 7, 2026.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on May 7, 2026.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on May 7, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 7, 2026.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on May 7, 2026.
CMS has cited this home for F0692 2 times since 2022.
Citation F0730. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on May 7, 2026.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on May 7, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on May 7, 2026.
CMS has cited this home for F0761 3 times since 2022.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 7, 2026.
CMS has cited this home for F0880 3 times since 2022.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on May 7, 2026.
10 citations
Fire safety inspection on April 17, 2026
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 27, 2026.
CMS has cited this home for K0353 3 times since 2022.
Citation K0362. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on April 21, 2026.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for K0920 2 times since 2024.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on May 1, 2026.
CMS has cited this home for K0321 2 times since 2022.
Citation K0342. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
CMS lists it as corrected on April 21, 2026.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on May 1, 2026.
CMS has cited this home for K0355 3 times since 2022.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 21, 2026.
CMS has cited this home for K0363 2 times since 2024.
Citation K0914. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on April 21, 2026.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on May 8, 2026.
CMS has cited this home for K0919 3 times since 2022.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 23, 2026.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
2 citations
Fire safety inspection on February 19, 2026
CMS lists this as a complaint inspection.
Citation K0161. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on February 27, 2026.
CMS has cited this home for K0161 3 times since 2022.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on February 20, 2026.
CMS has cited this home for K0293 2 times since 2022.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 5 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
3 citations
Health inspection on December 19, 2024
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on January 9, 2025.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 9, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on January 9, 2025.
10 citations
Fire safety inspection on December 19, 2024
CMS lists this as a standard inspection.
Citation K0341. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on December 26, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on January 8, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 13, 2025.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on January 17, 2025.
Citation K0161. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on December 24, 2024.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on December 24, 2024.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on January 17, 2025.
Citation K0711. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on January 17, 2025.
Citation K0753. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on January 17, 2025.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on January 17, 2025.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
17 citations
Health inspection on March 28, 2022
CMS lists this as a standard inspection.
Citation F0801. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
CMS lists it as corrected on April 20, 2022.
Citation F0802. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
CMS lists it as corrected on April 20, 2022.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 20, 2022.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 20, 2022.
Citation F0582. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on April 20, 2022.
Citation F0604. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on April 20, 2022.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 20, 2022.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on April 20, 2022.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
CMS lists it as corrected on April 20, 2022.
Citation F0808. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
CMS lists it as corrected on April 20, 2022.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on April 20, 2022.
Citation F0908. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on April 20, 2022.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on April 20, 2022.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 20, 2022.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on April 20, 2022.
Citation F0881. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on April 20, 2022.
Citation F0888. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure staff are vaccinated for COVID-19
CMS lists it as corrected on April 20, 2022.
10 citations
Fire safety inspection on March 28, 2022
CMS lists this as a standard inspection.
Citation K0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on April 11, 2022.
Citation E0026. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on April 11, 2022.
Citation K0161. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on April 11, 2022.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on April 11, 2022.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on April 11, 2022.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on April 11, 2022.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 11, 2022.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 11, 2022.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on April 11, 2022.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on April 11, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BOWERSOX, KIM5% or greater indirect ownership interest · 50% · since 10/30/2014
- BOWERSOX, ROBERT5% or greater indirect ownership interest · 50% · since 10/30/2004
- TUBERA, MELANIEOperational/managerial control · not applicable · since 04/01/2014
Questions
When was Carmel Hills Care Center last inspected?
CMS lists April 17, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Carmel Hills Care Center have?
CMS lists 39 health citations since March 28, 2022. CMS also calls these deficiencies.
Has Carmel Hills Care Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Carmel Hills Care Center?
Its CMS overall star rating is 2 of 5.
Is Carmel Hills Care Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.