Resident #1 was discovered on September 28, 2025, at 11:30 PM after an unwitnessed fall. Staff found a small skin tear on the left elbow and a bump on the back of the head. But the more alarming signs emerged when nurses tried to check vital signs.
The thermometer couldn't read the resident's temperature at all. Staff attempted to take blood pressure both with a machine and manually but failed because the resident was shaking uncontrollably. Heart rate registered at 115, and oxygen saturation measured just 73 percent, though staff noted this "may be inaccurate due to how cold the resident was."
Emergency department records revealed the severity of the situation. When Resident #1 arrived at the hospital around midnight, a rectal temperature reading showed 85.6 degrees Fahrenheit. Normal body temperature ranges from 97 to 99 degrees.
The resident was in respiratory distress, requiring nebulizer treatments, intravenous antibiotics, and "lots of warmed intravenous fluids," according to Registered Nurse #101, who received the patient in the emergency department.
"There was no plausible explanation provided for the hypothermia," the emergency room nurse stated during an October 23 interview with inspectors.
Yet nursing home records told a starkly different story. A physician's progress note from the same night described the resident as having "stable" vital signs with "no mental status changes." The note mentioned no hypothermia, no unreadable temperature, and no respiratory distress.
Hospital records documented the resident presented with "concerning" hypothermia, rapid heart rate in the 160s, abnormally rapid breathing at 30 breaths per minute, and dangerously low oxygen levels in the mid-80s.
Director of Nursing #1, who was on call that night, said Licensed Practical Nurse #4 called to report the fall and acute condition change, mentioning staff couldn't obtain vital signs. But crucial details never reached the supervisor.
"It was not reported to them that the resident was found naked, cold and shivering, or that their body temperature was unreadable because it was so low," according to the inspection report.
The nursing director admitted not having this information during the initial investigation and said they "did not ask any further questions about the resident."
Administrator #1 acknowledged the facility never established a timeline for when the fall occurred. This left a critical gap in understanding how long Resident #1 remained on the floor before discovery.
The investigation's shortcomings extended beyond timeline questions. Director of Nursing #1 confirmed that staff never interviewed Resident #1's roommate, despite the roommate being "alert and oriented" and potentially able to provide information about the fall.
"Resident #1's roommate should have been interviewed as the roommate was alert and oriented and may have been able to provide information pertaining to the fall," the nursing director told inspectors on October 8.
The facility's Summary of Investigation Report, completed September 29, documented the fall, injuries, and hospital transfer but failed to address fundamental questions about the incident. The report made no mention of investigating how long the resident lay on the floor or what factors contributed to the severe hypothermia.
Federal inspectors found the investigation inadequate, noting it "did not include an investigation of the amount of time Resident #1 was on the floor or factors that contributed to why Resident #1 was cold and their body temperature was unreadable."
The inspection report also highlighted that the facility's investigation failed to address "discrepancies between the Physician progress note" and what actually occurred, including the conflicting accounts of vital signs and mental status.
Hospital emergency department notes painted a picture of a medical crisis requiring immediate intervention. The resident needed multiple treatments to stabilize breathing, combat infection, and restore normal body temperature through warmed fluids.
Meanwhile, the nursing home's own documentation suggested a routine fall with stable vital signs and no significant concerns.
Chestnut Park Rehabilitation and Nursing Center received a citation for failing to conduct a thorough investigation of the incident, classified as having potential for minimal harm affecting few residents.
The resident was hospitalized with changes in mental status following the hypothermia episode, according to the facility's investigation summary.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chestnut Park Rehabilitation and Nursing Center from 2025-10-27 including all violations, facility responses, and corrective action plans.
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