Kit Carson Nursing & Rehabilitation Center
KIT CARSON NURSING & REHABILITATION CENTER in JACKSON, CA — inspection on March 30, 2026.
Found 5 citations. 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.
Inspection Findings
Review of a facility policy titled Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, revised 1/2026, indicated nursing staff were to assess and document gastrointestinal symptoms, including a .quantitative and qualitative description of diarrhea (how many episodes.amount, consistency, etc). abdominal assessment, and onset, duration, frequency, and severity of signs and symptoms.
The policy further indicated staff were to characterize symptoms, including location and nature of abdominal pain, and to monitor the resident's response and progression, including the frequency, severity, and duration of abdominal pain and bowel movements.
Review of a policy titled Physician Notification, revised 1/2026, indicated licensed nursing staff were to promptly notify the physician of any significant change in a resident's condition, including changes in physical status such as pain, diarrhea, decreased intake, and abnormal laboratory results.
The policy further indicated that if the physician did not respond within a reasonable timeframe, nursing staff were to notify an alternate physician.
The policy indicated staff were to document all attempts to notify the physician, including, .date and time of physician notification. brief description of information communicated.and physician response. in the resident's clinical record.
Review of a facility policy titled Change of Condition revised 7/2024, indicated, . It is the policy of this facility that all changes in resident condition will be communicated to the physician. PURPOSE To clearly define guidelines for timely notification of a change in resident condition for immediate intervention.Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician.All nursing actions/interventions will be documented in the licensed progress notes as soon as possible after resident needs have been met.All symptoms and unusual signs will be communicated to the physician promptly.Document resident change of condition and response in nursing progress notes, on Twenty-Four Hour Report and update resident Care Plan, as indicated.
Review of a facility policy titled Licensed Nurses Notes revised 1/2025, indicated,.A nursing assessment shall be completed for each resident by a licensed nurse and coordinated with the Interdisciplinary Team.Changes in the resident's condition that require a telephone call to the physician shall be recorded by the nurse reporting.
The physician shall be notified promptly, as well as the resident and the resident's personal representative or an interested family member (when appropriate), of the following events.Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a resident.
All attempts to notify the physician shall be recorded in the resident's health record and shall include: date, time, name of the physician called, resident's condition, name of the person acknowledging contact, and the response to the call.
Acute conditions of the resident shall have adequate follow-up notes concerni
056198 03/30/2026
Kit Carson Nursing & Rehabilitation Center 811 Court Street Jackson, CA 95642
jelly, she would have contacted the family to discuss the situation.
The ST explained that this would
procedure titled, [Name of facility] - Resident Food Preferences, indicated, POLICY: It is the policy of
PROCEDURES: .
The dietitian will discuss resident food preferences with the resident [Resident 1] when such preferences conflict with a prescribed diet.
The clinical dietitian and nursing staff, assisted by the physician, will identify any nutritional issues or dietary restrictions that might affect the facility's efforts to accommodate resident [Resident 1] preferences. In conjunction with the physician, the dietitian or nursing staff will document reasons why restrictions are necessary and/or why the facility cannot accommodate resident [Resident 1] preferences.
056198 03/30/2026
Kit Carson Nursing & Rehabilitation Center 811 Court Street Jackson, CA 95642
During a review of the facility
necessary to provided nursing and related care and services for all residents in accordance with
certified nursing assistants are available .24 hours a day, seven (7) days a week to provide competent resident care services. including .responding to resident needs. and .assuring resident safety.
The policy also stated that .staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment. and that staffing considerations include resident conditions, limitations and acuity.During a review of the facility's policy titled CALL LIGHT/BELL revised on 1/2026, the policy indicated the facility provides residents .a means of communication with nursing staff. the policy further indicated staff to .answer the call light within a reasonable time (3 - 5 minutes). and to .respond to the request.During a review of an undated facility's policy and procedure titled Registry / Agency Staff Utilization Policy, the policy indicated the facility ensures registry or agency personnel .utilized to supplement staffing meet federal, state, and facility regulatory requirements, possess appropriate qualifications, and adhere to the facility's standards of care, policies, and procedures.
The policy further indicated that .registry personnel shall be used when necessary to maintain safe staffing levels and resident care standards. and that registry staff receive .orientation, supervision, and performance monitoring while working at the facility.
The polity also indicated registry personnel must .follow all facility clinical protocols and documentation requirements. and are accountable for .accurate documentation.During a review of the facility's policy titled Resident Rights, revised on 1/2026, the policy indicated employees shall treat residents .with kindness, respect, and dignity. the policy further indicated residents have the right to .a dignified existence. and to .be treated with respect, kindness and dignity.
056198 03/30/2026
Kit Carson Nursing & Rehabilitation Center 811 Court Street Jackson, CA 95642
During a review of the facility's policy titled Storage of Medications revised on 1/2026, the policy indicated medications were to be .stored safely, securely, and properly. and were accessible only to licensed nursing personnel and authorized staff.
The policy indicated medication carts and supplies were to be .locked or attended by persons with authorized access.
The policy also indicated medication storage conditions were monitored on a regular basis, and corrective action was taken if problems were identified.
056198 03/30/2026
Kit Carson Nursing & Rehabilitation Center 811 Court Street Jackson, CA 95642
stated residents who were treated for heart failure, nurses should hold their blood pressure
reviewed Resident 1's January 2026 MAR and confirmed that Resident 1 received metoprolol despite
1/6/26, 107/58 on 1/7/26, 107/56 on 1/12/26, 103/59 on 1/19/26, 109/64 on 1/24/26 and for 5:00 PM administrations - 100/59 on 1/5/26, 104/70 on 1/9/26, 99/61 on 1/10/26 and 102/64 on 1/17/26.
The DON reviewed Resident 1's February 2026 MAR and confirmed additional administrations of metoprolol when Resident 1's systolic blood pressure was below 110, including: 9:00 AM administrations - 104/60 on 2/5/26, 102/56 on 2/10/26 and for 5:00 PM administration - 106/56 on 2/13/26.
The DON stated that administering metoprolol when the systolic blood pressure was below 110 was not consistent with the facility's process for residents treated for hypertension.
The DON stated that she expected nurses to follow the facility's process, assess the resident, and contact the physician when the blood pressure readings were low.
The DON further stated that clear medication parameters should have been in place, and without those parameters Resident 1's safety was at risk.
The DON reviewed Resident 1's care plans and confirmed Resident 1 did not have a care plan addressing hypertension or the use of metoprolol, including monitoring for potential adverse effects related to the medication and its black box warning (BBW - the strongest safety warning for a medication about serious risks).
The DON reviewed Resident 1's February Medication Regimen Review (MRR - a regular check of all a person's medications to make sure they are safe and appropriate) completed by the consultant pharmacist and confirmed that Resident 1 was included in the review, but the pharmacist did not make any recommendation regarding the lack of medication parameters or the low blood pressure readings.Review of facility policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol, revised 1/25, indicated, Assessment and Recognition - The physician will help identify individuals with a significant risk for having acute changes of condition during their stay . someone with unstable vital signs . the nurse shall assess and document/report .
Vital signs .
All current medications .
The physician will help identify medications . that are associated with adverse consequences that could cause significant changes in condition.Review of facility P&P titled, PHYSICIAN NOTIFICATION, revised 1/26, indicated, . It is the policy of this facility to notify the attending physician of any significant change in a resident's condition.
Licensed nurse shall promptly notify primary physician of any significant change in resident's condition. adverse effects from medications, e.g. [for example] side effects noted .Review of facility P&P titled, POLICY AND PROCEDURE IN MEDICATION ADMINISTRATION, revised 1/26, indicated, Policy - Medications shall be administered in accordance with our established policies and procedures.
Medication for hypertension that requires parameter before administration should be complied with.