Carmel Hills Care Center

Name: Carmel Hills Care Center
Address: 23795 W. R. HOLMAN HIGHWAY, Monterey, CA, 93940, US
Telephone: 8316241875

23795 W. R. Holman Highway, Monterey, CA 93940 · Monterey County · 99 certified beds · avg 96 residents/day · certified since Dec 31, 1971

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.94

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (39)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Apr 17, 2026	F · Potential for harm, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Apr 17, 2026	F · Potential for harm, facility-wide	The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Apr 17, 2026	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 17, 2026	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 17, 2026	E · Potential for harm, repeated	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Apr 17, 2026	E · Potential for harm, repeated	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Apr 17, 2026	E · Potential for harm, repeated	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Apr 17, 2026	E · Potential for harm, repeated	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Apr 17, 2026	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Apr 17, 2026	E · Potential for harm, repeated	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Apr 17, 2026	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Apr 17, 2026	D · Potential for harm, one-off	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Apr 17, 2026	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 17, 2026	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Apr 17, 2026	D · Potential for harm, one-off	The facility did not observe each nurse aide's job performance or provide regular training as required.
Apr 17, 2026	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Apr 17, 2026	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Apr 17, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 17, 2026	D · Potential for harm, one-off	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Dec 19, 2024	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 19, 2024	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 19, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 28, 2022	F · Potential for harm, facility-wide	The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Mar 28, 2022	F · Potential for harm, facility-wide	The facility did not have enough support staff to safely and effectively run its food and nutrition service.
Mar 28, 2022	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 28, 2022	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 28, 2022	E · Potential for harm, repeated	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Mar 28, 2022	E · Potential for harm, repeated	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Mar 28, 2022	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Mar 28, 2022	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 28, 2022	E · Potential for harm, repeated	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Mar 28, 2022	E · Potential for harm, repeated	The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows.
Mar 28, 2022	E · Potential for harm, repeated	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Mar 28, 2022	E · Potential for harm, repeated	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Mar 28, 2022	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Mar 28, 2022	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Mar 28, 2022	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Mar 28, 2022	D · Potential for harm, one-off	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Mar 28, 2022	D · Potential for harm, one-off	The facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 19).

Year	Citations	Worst severity that year
2022	17	F
2024	3	F
2026	19	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.94	4.31	3.95	top 16% in California; top 14% in the U.S.
Registered Nurse hours	0.69	0.61	0.69	top 25% in California; top 38% in the U.S.
Weekend total nurse staffing	4.39	3.90	3.50	top 17% in California; top 14% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.47	0.51	0.48	top 34% in California; top 36% in the U.S.
Total nursing staff turnover (%)	31.6	36.7	45.8	top 35% in California; top 17% in the U.S.
RN turnover (%)	25.0	38.1	42.9	top 26% in California; top 20% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.32, RN 0.60, weekend 3.84. Staffing rating: 5/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 2/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Bowersox, Kim	Individual	5% or Greater Indirect Ownership Interest	50%	10/30/2014
Bowersox, Robert	Individual	5% or Greater Indirect Ownership Interest	50%	10/30/2004
Bowersox, Kim	Individual	W-2 Managing Employee	NOT APPLICABLE	10/30/2004
Bowersox, Robert	Individual	W-2 Managing Employee	NOT APPLICABLE	10/30/2004
Dorsey, Carole	Individual	W-2 Managing Employee	NOT APPLICABLE	06/06/2014
Helenius, Mikko	Individual	Contracted Managing Employee	NOT APPLICABLE	06/01/2010
Tubera, Melanie	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2014

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Where do you post your daily staffing numbers, and can I see today's?"
"Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
"What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
"What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
"How do you coordinate and monitor care for residents who receive dialysis?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Westland House	2.3 mi	Monterey, CA	★★★☆☆	4/5
Monterey Post Acute	3.9 mi	Monterey, CA	★★★★☆	3/5
Cypress Ridge Care Center	3.9 mi	Monterey, CA	★★★★☆	3/5
Oceanview Post Acute	4.0 mi	Pacific Grove, CA	★★★★★	4/5
Canterbury Woods	4.3 mi	Pacific Grove, CA	★★★★★	5/5
Forest Hill Manor Health Center	4.3 mi	Pacific Grove, CA	★★★★☆	3/5
Katherine Healthcare	12.2 mi	Salinas, CA	★★☆☆☆	2/5
Pacific Coast Post Acute	12.6 mi	Salinas, CA	★★★★☆	3/5
Salinas Valley Post Acute	12.7 mi	Salinas, CA	★★★☆☆	3/5
Coastal Post Acute	12.8 mi	Salinas, CA	★★★★☆	3/5
Windsor the Ridge Rehabilitation Center	12.8 mi	Salinas, CA	★★★★★	4/5

Compare this facility with the 3 closest →

All facilities in Monterey →

Facility data as of CMS processing date 2026-08-01. CCN 056055.

The Care File

Visit checklist — Carmel Hills Care Center

23795 W. R. Holman Highway, Monterey, CA 93940 · 8316241875

Health inspection rating 2/5 · CMS overall 3/5· Fines (3y): $0

Questions for the administrator:

☐ "Where do you post your daily staffing numbers, and can I see today's?"
☐ "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
☐ "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
☐ "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
☐ "How do you coordinate and monitor care for residents who receive dialysis?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 056055 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)