Carmel Mountain Rehab: Hypothermia Emergency Delay - CA
The December incident at Carmel Mountain Rehabilitation & Healthcare Center involved a resident with a documented history of hypothermia who was found shivering with cold skin as his body temperature plummeted below normal levels.
Licensed Nurse 1 received the initial report from a certified nursing assistant around 9:30 a.m. on December 14, 2024. The aide had measured the resident's temperature at 92 degrees Fahrenheit. Normal body temperature ranges from 97 to 99 degrees.
The nurse told federal inspectors she was busy at the time and asked the aide to retake the resident's temperature instead of assessing the patient herself.
By 11:49 a.m., the resident's temperature had dropped further to 90.2 degrees. The patient was visibly shivering and his skin felt cold to the touch. Hypothermia occurs when body temperature falls below 95 degrees.
Licensed Nurse 1 finally initiated a change of condition evaluation and contacted the physician around noon. The doctor ordered immediate hospital transfer due to hypothermia, and the resident was transported by ambulance to the emergency room at 11:59 a.m.
During interviews with federal inspectors in September, the nurse acknowledged her failure. "LN 1 stated she should have assessed Resident 1 temperature right away," according to the inspection report.
The resident had been admitted to the facility earlier that year with multiple diagnoses including hypothermia, according to his physician's December examination.
Another licensed nurse became involved when the resident's family member approached her around lunchtime, asking staff to check the patient's temperature. Licensed Nurse 2 found the resident sitting in his room with a blanket wrapped around him.
"LN 2 stated Resident 1's low temperature should be addressed and notify the physician right away," inspectors documented.
The facility's Director of Nursing confirmed the severity of the situation during her interview with federal inspectors. She stated that hypothermia was a medical emergency requiring immediate physician notification, and that the resident's temperature of 92 degrees "was not normal."
The nursing home's own policy requires staff to communicate all changes in resident condition to physicians promptly. The policy, revised in June 2013, specifically states that "all symptoms and unusual signs will be communicated to the physician promptly."
Federal inspectors found the facility failed to provide appropriate treatment according to physician orders and the resident's medical needs. The violation resulted in delayed assessment and treatment that could have been prevented with proper nursing response.
The inspection, conducted as part of a complaint investigation in September 2025, documented how basic nursing protocols were ignored during a medical emergency. Staff had clear indicators that immediate action was needed but failed to follow established procedures for reporting critical changes in patient condition.
The resident's deteriorating condition over the two-and-a-half-hour period demonstrated the consequences of delayed medical intervention. What began as a concerning temperature reading at 92 degrees progressed to a more serious 90.2 degrees before emergency medical care was finally sought.
The case illustrates how staffing priorities and time management decisions can directly impact patient safety in nursing home settings. The licensed nurse's admission that she was "too busy" to immediately assess a resident with dangerously low body temperature raises questions about facility staffing levels and emergency response protocols.
Federal regulators classified the violation as causing minimal harm or potential for actual harm to residents. The deficiency affected few residents at the 120-bed facility located on Avenue of Industry in San Diego.
The nursing home was required to submit a plan of correction to address the identified failures in temperature monitoring and physician notification procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carmel Mountain Rehabilitation & Healthcare Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER in SAN DIEGO, CA was cited for violations during a health inspection on September 4, 2025.
Licensed Nurse 1 received the initial report from a certified nursing assistant around 9:30 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.