Kit Carson Nursing: Resident Dies After Bowel Perforation - CA
She had walked into a hospital with abdominal pain. She left in a body bag.
A CT scan taken after her admission showed inflammation of the colon and raised the possibility of gas trapped inside the bowel wall, a sign of dying tissue. Surgeons performed an exploratory procedure on February 12 and found what they were looking for: a perforated sigmoid colon with fecal contamination. They removed part of her colon and created a colostomy, an opening through her abdominal wall to route waste outside her body.
It wasn't enough.
Three days later, on February 15, surgeons took her back into the operating room. What they found was necrotizing fasciitis, the condition sometimes called flesh-eating disease, a rapidly spreading bacterial infection that destroys the connective tissue and fat beneath the skin. The operative note documented necrotic fascia and mucopurulent serosanguineous fluid. Her blood pressure had dropped to the point where she required Levophed, a drug used in critical care to keep blood pressure from collapsing entirely in patients in shock.
She was taken off the ventilator the following day and placed on a Vapotherm device, a non-invasive machine that delivers high-flow oxygen to patients in respiratory distress. She never recovered. She died at 3:21 in the morning on February 25.
The inspection, completed March 30, examined what happened before she reached the hospital. The report's findings centered on whether nursing staff at Kit Carson tracked and communicated her deteriorating condition the way the facility's own written policies required them to.
Those policies were detailed. The facility's bowel disorder protocol, revised just two months before her death in January 2026, instructed nurses to document gastrointestinal symptoms with specificity: how many episodes of diarrhea, the amount, the consistency, the onset, the duration. It required an abdominal assessment and documentation of the location and nature of any abdominal pain. The policy required staff to monitor and record how symptoms progressed over time.
A separate physician notification policy, also revised in January 2026, told licensed nurses to contact a doctor promptly when a resident showed any significant change in condition, including pain, diarrhea, decreased food intake, or abnormal lab results. If the physician didn't respond within a reasonable time, nurses were to call an alternate physician. Every attempt to reach a doctor was to be recorded in the clinical chart, with the date, the time, what was communicated, and what the physician said in response.
A change-of-condition policy from 2024 stated that any sudden or serious change in a resident's physical or mental status would be communicated to the physician, and that all symptoms and unusual signs would be reported promptly.
The inspection found a level of actual harm and identified the deficiency as affecting a small number of residents.
What the report does not describe, in the portion available, is what nurses actually documented, what calls were or were not made, or how long her symptoms went unaddressed before she was sent to the hospital. The gap between what the policies required and what the inspectors found worth citing is the story. Facilities do not receive actual harm findings for following their own protocols.
She had a perforated colon. The perforation does not happen instantly. Ischemic colitis, the condition the CT scan could not rule out on arrival, develops when blood flow to the colon is reduced over time. The bowel wall weakens. Without intervention, it breaks down. The inspectors arrived at Kit Carson six weeks after she died.
Her colostomy bag was not there to see. Neither was she.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kit Carson Nursing & Rehabilitation Center from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Kit Carson Nursing & Rehabilitation Center
- Browse all CA nursing home inspections
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 17, 2026 · Our methodology
KIT CARSON NURSING & REHABILITATION CENTER in JACKSON, CA was cited for violations during a health inspection on March 30, 2026.
She had walked into a hospital with abdominal pain.
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.
Frequently Asked Questions
- What happened at KIT CARSON NURSING & REHABILITATION CENTER?
- She had walked into a hospital with abdominal pain.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in JACKSON, CA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from KIT CARSON NURSING & REHABILITATION CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 056198.
- Has this facility had violations before?
- To check KIT CARSON NURSING & REHABILITATION CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.