Carmel Mountain Rehab: Hypothermia Delay Harms Resident - CA
At Carmel Mountain Rehabilitation & Healthcare Center, a licensed nurse learned at 9:30 a.m. on December 14, 2024 that Resident 1's temperature had dropped to 92 degrees Fahrenheit. That is well below the threshold for hypothermia, which the resident's own physician had documented as a diagnosis just four days earlier. The nurse, identified in inspection records as Licensed Nurse 1, said she was occupied at the time and asked a certified nursing assistant to take the temperature again.
Nobody called the doctor.
Two and a half hours passed. At 11:49 a.m., the temperature was 90.2 degrees. The resident was shivering. His skin was cold. A family member had gone looking for a nurse to check on him around noon, approaching a second nurse in the hallway. That nurse, Licensed Nurse 2, found the resident sitting in his room, a blanket wrapped around him.
The physician was finally notified around noon. The order to transfer came at 11:59 a.m. Resident 1 was sent to the emergency room by ambulance.
Licensed Nurse 1, when interviewed by inspectors on September 4, 2025, did not dispute what had happened. "She stated she should have assessed Resident 1's temperature right away," the inspection report noted. Licensed Nurse 2 told inspectors that a temperature that low "should be addressed and notify the physician right away." The Director of Nursing said the same: notify immediately, because a temperature of 92 degrees "was not normal" and hypothermia was "a medical emergency."
Everyone agreed, after the fact, on what should have been obvious at 9:30 in the morning.
The inspection was triggered by a complaint and conducted on September 4, 2025. Inspectors reviewed the facility's own change-of-condition records, which documented the 9:30 a.m. reading of 92 degrees and noted the resident was rechecked "at around 11am with readings at 90.2." The facility's internal policy, revised in June 2013, states that changes in resident condition and unusual signs will be communicated to the physician promptly. The gap between the first recorded temperature and the physician notification was more than two hours.
The Director of Staff Development was present during the initial interview with Licensed Nurse 1. The inspection report does not indicate that any explanation was offered for the delay beyond the nurse saying she was busy.
Resident 1 was admitted to Carmel Mountain with hypothermia listed among his diagnoses. The condition, in which core body temperature drops below 95 degrees, is dangerous in elderly patients and can become life-threatening quickly. A temperature of 90.2 degrees represents severe hypothermia. The resident's physician had documented the diagnosis on December 10, 2024, four days before the morning a nursing assistant flagged a temperature of 92 and was told to check again later.
The inspection report classified the violation as causing minimal harm or potential for actual harm. It identified the failure as affecting few residents. Neither designation changes what the records show: a man sat cold and shivering in his room for hours while the people responsible for his care waited.
His family member eventually went looking for someone to help him.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER in SAN DIEGO, CA was cited for violations during a health inspection on September 4, 2025.
At Carmel Mountain Rehabilitation & Healthcare Center, a licensed nurse learned at 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.