Other·March 27, 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 facility reported incident #CA00613838 Representing the Department of Public Health: HFEN, 41054 HFEN, 26663 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 04/01/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to prevent a fall for one of three sampled residents (Resident 1) when staff supervison and assistance during transfer and toileting was not provided, a new fall risk assessment was not conducted when Resident 1 had a change of condition (COC) and the 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: JDD611 Facility ID: CA030000074 If continuation sheet 1 of 8 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 03/01/2019 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 care plan was not followed or updated to identify new interventions to prevent a fall, based on Resident 1's COC. This deficient practice resulted in Resident 1's fall, in which she sustained a broken hip. Findings: A review of Resident 1's Face Sheet indicated she was admitted in 2016 with diagnoses including brain cancer, high blood pressure and a urinary tract infection (UTI). A review of the clinical record for Resident 1 included the following documents: A Minimum Data Set (MDS, an assessment tool) dated 9/19/18, which described Resident 1 as having severe cognitive impairment, scoring 7 out of 15 possible points (scoring range is 0-15, with 15 reflecting no memory impairment) on the Brief Interview for Mental Status (BIMS). The MDS also described Resident 1 as requiring supervision or oversight and encouragement or cueing for transfer and limited assistance, in which staff provided guided maneuvering of limbs or other non-weight-bearing assistance, for toileting. A Fall Risk Assessment (FRA), completed on 9/19/18, categorized Resident 1 as being at high risk for falls. A physician's progress note, dated 10/28/18, indicated Resident 1 was weak and confused. An Order Summary Report, dated 11/5/18, reflected, "Resident 1 is incapable of giving informed consent and/or able to participate in treatment plan." A nursing progress note, dated 11/25/18 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDD611 Facility ID: CA030000074 If continuation sheet 2 of 8 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 03/01/2019 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 written at 12:33 p.m., indicated Resident 1 was, "Noted with COC [change of condition], more confusion than per norm, generalized weakness, inability to stand, stuttering, staring at ceiling singing, answering questions inappropriately and episodes of incontinence with urine." A Resident Transfer Record, dated 11/25/18, indicated Resident 1 was sent to a General Acute Care Hospital (GACH) due to an altered level of consciousness and weakness upon standing. A nursing progress note, dated 11/25/18 and written at 8:36 p.m. by Licensed Nurse 2 (LN 2), reflected Resident 1 returned to the facility from the GACH at 5:30 p.m. with a diagnosis of a UTI and an order for oral antibiotics. The note also indicated Resident 1 was, "Still confused." No updated FRA was documented in the electronic medical record (EMR) to address Resident 1's change of condition on 11/25/18. There was no documented evidence of a resident assessment upon return from the GACH. A nursing progress note, dated 11/26/18 and written at 4:02 a.m. by LN 3, indicated Resident 1 was noted with increased confusion and was slow to respond. A nursing progress note, dated 11/27/18 and written at 6:55 p.m. by LN 4, indicated Resident 1 was alert with confusion and short term memory loss, and appeared more confused. A nursing progress note, dated 11/28/18 and written at 12:45 p.m. by LN 5, indicated Resident 1 was found sitting on the floor in front of the toilet with her wheelchair in the bathroom doorway. Resident 1's left leg was bent and under her right leg, which was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDD611 Facility ID: CA030000074 If continuation sheet 3 of 8 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 03/01/2019 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 outstretched in front of her. Resident 1 reported, "Terrible" pain and was unable to move the left leg without pain. Resident 1 was transferred to a GACH for further evaluation. The GACH Emergency Department Physician notes, dated 11/28/18, indicated Resident 1's admitting diagnoses included severe sepsis (blood stream infection) and broken proximal (nearest to the point of attachment) end of the left femur (thigh bone). The GACH Discharge Summary, dated 12/6/18, reflected Resident 1's condition worsened, and Resident 1 died on 12/6/18. Resident 1's certified Death Certificate listed the cause of death as cardiopulmonary arrest (a sudden loss of blood flow resulting from the heart failing to effectively pump) secondary to respiratory failure (impaired lung function that leads to inadequate delivery of oxygen to the body's tissues), severe sepsis and acute renal failure (sudden failure of the kidneys to filter waste products from the blood). A Risk For Injury Care Plan, initiated on 1/14/16, indicated the goal of preventing or minimizing falls for Resident 1. Interventions initiated on 1/14/16 included; assisting the resident as needed, resident assessment, constant safety reminders daily and as needed, providing a safe environment, encouraging the resident to use her call light and a non-skid wheelchair pad. The care plan was last updated on 10/2/18 and reflected no additional interventions were taken to address Resident 1's change of condition on 11/25/18. In an interview on 12/12/18 at 1:15 p.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 required supervision for toileting and she stated supervision meant, "You stand by and keep an eye on them." CNA 1 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDD611 Facility ID: CA030000074 If continuation sheet 4 of 8 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 03/01/2019 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 she was aware of Resident 1 frequently taking herself to the bathroom without staff supervison. CNA 1 stated she noticed Resident 1 was having a hard time standing. In an interview on 12/12/18 at 1:34 p.m., CNA 2 stated supervision meant the CNA watched the resident transfer when going to the bathroom and then stood by. CNA 2 stated Resident 1 was supposed to be supervised, but often used her wheelchair to go to the bathroom and transferred herself to the toilet. CNA 2 stated Resident 1 was, "A lot more weaker," and recently more incontinent than before. CNA 2 stated Resident 1 had recently, "Started forgetting faces she always knew." In an interview on 12/12/18 at 1:50 p.m., LN 1 stated supervision for transfer meant staff were to stand by, survey for safety, lock the wheelchair, and verbally direct the resident. Supervision and assistance of 1 staff member meant the CNA explained the process and verbally directed the resident. If the resident asked for privacy, the CNA closed the door but must stay on the other side of the door unless the resident was fully alert and oriented. LN 1 confirmed Resident 1 required supervision, but was aware she often took herself to the bathroom. LN 1 stated Resident 1 was starting to forget things a lot recently. In an interview on 12/12/18 at 2:25 p.m., the MDS Coordinator stated transfer supervision meant staff were to stand by, and limited assistance toileting meant staff verbally directed the resident, took them by the elbow, but no weight bearing on staff's part, "We don't want [residents] to do it alone." The MDS Coordinator stated toileting assistance meant the CNA was in the room or outside the room in the hall. The MDS Coordinator also confirmed she interviewed the residents when completing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDD611 Facility ID: CA030000074 If continuation sheet 5 of 8 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 03/01/2019 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 the MDS assessment, and had assessed Resident 1 to be supervision for transfer and limited assistance for toileting. In an interview on 12/17/18 at 9:10 a.m., CNA 3 stated Resident 1 had become very incontinent prior to the fall and Resident 1 required supervision to transfer. CNA 3 stated at the time of the fall, 11/28/18 at 12:45 p.m., she was assigned to care for Resident 1. CNA 3 stated she was getting ready to shower another resident when she heard Resident 1's screams for help and ran to Resident 1's room. CNA 3 confirmed Resident 1 was found in the bathroom and was unsupervised. In an interview on 12/17/18 at 9:40 a.m., LN 5 stated at the time of Resident 1's fall, Resident 1 was being treated for a UTI. LN 5 stated Resident 1 had confusion and increased incontinence. LN 5 stated she was not Resident 1's nurse on 11/28/18, but CNAs called her to Resident 1's room. LN 5 stated she was standing at Nursing Station 2 and ran down the hallway to Resident 1's room. LN 5 stated Resident 1 was taking herself to the bathroom without staff supervison or assistance. In a telephone interview on 12/17/18 at 11:10 a.m., CNA 5 stated she was standing at Nursing Station 2 and heard Resident 1's yelling down the hallway. CNA 5 stated she ran to the room with CNA 4 and found Resident 1 sitting on the floor facing the toilet with her left leg folded under her outstretched right leg. CNA 5 stated she saw Resident 1's wheelchair pushed back against the sink and believed Resident 1 did not lock her wheelchair before attempting to transfer herself to the toilet without staff supervision. CNA 5 stated Resident 1 required supervision. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDD611 Facility ID: CA030000074 If continuation sheet 6 of 8 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 03/01/2019 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 A review of the facility's Accident/Fall Risk/Injury Assessment and Prevention Policy stipulated, "It is the responsibility of nursing to complete an accident/fall risk/injury assessment within 7 days upon admissions, quarterly, annually, and as often as needed and with any significant change of condition." The policy also stipulated, "Check and assess resident's safety awareness since poor judgement, confusion and inability to comprehend could cause fall." In an interview on 12/17/18 at 11:30 a.m., the DON verified Resident 1 did not have the capacity to make decisions. The DON verified there was no documented evidence of an RN assessment when Resident 1 returned from the GACH, and between 11/25/18 and Resident 1's unwitnessed fall on 11/28/18. The DON confirmed no new FRA was completed on 11/25/18 for Resident 1 when she returned from the GACH with the UTI diagnosis. The DON also verified Resident 1 had some delirium (sudden, severe confusion due to physical or mental illness) with her UTI, and she was weaker when she returned from the GACH. The DON agreed Resident 1 was less safe to ambulate due to the UTI and it was the responsibility of staff to check on Resident 1. The DON stated staff should have performed frequent visual checks, every 30 minutes or every hour, on Resident 1 to assure supervision. The DON stated she could not provide evidence that a staff member was supervising or assisting Resident 1 with toileting at the time of the fall. The DON confirmed Resident 1's care plans were not updated to address Resident 1's delirium, increased incontinence, confusion, weakness or how staff would keep Resident 1 safe with the change of condition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JDD611 Facility ID: CA030000074 If continuation sheet 7 of 8 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 03/01/2019 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: JDD611 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000074 (X5) COMPLETE DATE If continuation sheet 8 of 8