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Complaint Investigation

Kit Carson Nursing & Rehabilitation Center

August 20, 2025 · Jackson, CA · 811 Court Street
Citations 1
CMS Rating 1/5
Beds 199
Provider ID 056198
Healthcare Facility
Kit Carson Nursing & Rehabilitation Center
Jackson, CA  ·  View full profile →
Inspection Summary

KIT CARSON NURSING & REHABILITATION CENTER in JACKSON, CA — inspection on August 20, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0690
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

During a concurrent interview and record review on 8/20/25 at 2:11 PM, with the DON, Resident 1's record titled, Progress Notes, dated 4/26/25 through 8/8/25 were reviewed.

The DON confirmed Resident 1's suprapubic catheter monitoring were not consistently completed for the 72-hour duration as required on the above dates and shifts.

The DON stated monitoring the suprapubic catheter for 72 hours after it was changed was to ensure if there was a change in Resident 1's condition, nursing could coordinate with the physician in case there were additional changes or orders that needed to be carried out.

The DON further stated there was a risk for Resident 1 to acquire an infection and was at risk for pain.

A review of the facility policy titled, Change of Condition, revised 7/24, indicated, .

Routine Medical Change .

All symptoms and unusual signs will be communicated to the physician promptly .

Document resident change of condition and response in nursing progress notes .

Follow-up .

The licensed nurse responsible for the resident will continue assessment and documentation every shift for seventy-two (72) hours . 3. A review of Resident 1's clinical document titled, Care Plan Report, undated, indicated there was not a care plan in place for Resident 1's suprapubic catheter changes or for Resident 1's UTI from 6/23/25.

During a concurrent interview and record review on 8/20/25 at 2:11 PM, Resident 1's care plans were reviewed with the DON.

The DON confirmed Resident 1's care plans had not been updated to include Resident 1's UTI on 6/23/25 and it should have been.

The DON further stated there was not a care plan in place for catheter changes and there should have been.

The DON stated the importance of having the care plans in place was to ensure licensed nurses had a guide on how to take care of the Resident 1's suprapubic catheter. A review of the facility policy and procedure titled, Policy and Procedure - Care Plan, revised 9/2024, indicated, . A care plan is the summation of the resident concerns, goals, approaches and interventions in order to meet the goals and help minimize if not totally eradicate residents' problems . the evidence of a care plan that has been reviewed should include but not be limited to the new interventions that have been added in addition to the current ones .

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Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in JACKSON, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from KIT CARSON NURSING & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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