Kit Carson Nursing & Rehabilitation Center
Inspection Findings
F-Tag F0690
F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
monitoring not noted 8/7/25 AM shift; monitoring not noted 8/7/25 NOC shift; monitoring not noted A review of Resident 1's clinical document titled Progress Notes, dated 6/23/35, indicated, . Resident [1] sent out to [local hospital] via ambulance on 6/23/25 @ [at] 1317 [1:17 PM] for c/o [complaint of] 10/10 [assessment tool for pain - pain is rated 1 through 10 with 10 being the worst pain] pain in SP [suprapubic] catheter site.
Catheter was just replaced at [local hospital] on 6/21/25. Resistance was noted when flushing [the process of rinsing the tube with sterile water or saline to clear out any blockages] and no output [urine] was noted
during flush. Resident [1] requested to be sent out to ED [emergency department]. A review of Resident 1's clinical document titled, [Outside hospital] ED Provider Notes, dated 6/23/25, indicated, . UA [urinalysis urine test that checks for signs of infection] suggests catheter-associated UTI [urinary tract infection] . Given UA consistent with UTI and prior culture [a laboratory test that checks a urine sample for bacteria, or other germs that can cause a UTI] history, empiric [brand name antibiotic] [antibiotic used to treat suspected infection] prescribed . 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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KIT CARSON NURSING & REHABILITATION CENTER in JACKSON, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.