Other·January 11, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of complaint #CA00534111. Representing the Department of Public Health: HFEN, 17332 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 01/04/2019 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VT4F11 Facility ID: CA030000074 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056198 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KIT CARSON NURSING & REHABILITATION CENTER 811 Court Street Jackson, CA 95642 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VT4F11 Facility ID: CA030000074 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056198 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KIT CARSON NURSING & REHABILITATION CENTER 811 Court Street Jackson, CA 95642 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview and record review, the facility failed to inform the Department of an allegation of suspected abuse for 2 of 2 sampled residents within 24 hours. As a result of this failure, the facility was out of compliance with state regulations. Findings: On 5/12/17 at 1 p.m., an interview was conducted with Supervising Nurse 1 (SN 1). SN 1 stated there was a concern about how Certified Nursing Assistant 1 (CNA 1) was speaking to residents. SN 1 stated it was reported that CNA 1 was cursing and talking aggressively to one or two residents. SN 1 stated this was reported, "a couple of days after it happened." SN 1 stated the allegation was reported to the Assistant Administrator (AA) who conducted an investigation. SN 1 was asked if the abuse allegation regarding CNA 1 on 3/28/17 was reported to the Department. SN 1 stated, "No because too many days had elapsed." An interview was conducted with the AA on 6/8/17 at 2:30 p.m. The AA was asked if the abuse allegation regarding CNA 1, reported on 3/28/17, had been reported to the Department. The AA stated because it was, "several days before the allegation had been reported to administration" the allegation had not been reported to the Department. The facility's Abuse Prevention Policies and Procedures, revision date 12/14 were reviewed. The section titled, Reporting Abuse to Facility Management included the following in part, "Policy: It is the duty of our employees...to punctually report any incident or suspected incident of neglect or Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VT4F11 Facility ID: CA030000074 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056198 (X3) DATE SURVEY COMPLETED 12/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KIT CARSON NURSING & REHABILITATION CENTER 811 Court Street Jackson, CA 95642 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE abuse, including injuries of an unknown source, and theft or misappropriation of Resident property to Facility management." The section titled, "Reporting Abuse to State Agencies and Other Entities/Individuals" the policy included the following in part, "All alleged/suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate State agencies and other entities or individuals as may be required by law...PROCEDURE: 1. If an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including Resident to Resident abuse) were reported, the Facility Administrator, or his/her designee, will promptly inform the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the Facility." On 6/8/17 at 2:30 p.m., the AA acknowledged she was aware of mandated reporter requirements and the facility's abuse reporting requirements, however the allegation had not been reported to the Department. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VT4F11 Facility ID: CA030000074 If continuation sheet 4 of 4