Other·March 19, 2026

KIT CARSON NURSING & REHABILITAT Code of Federal Regulations, Title 42, Section 483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. Code of Federal Regulations, Title 42, Section 483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Code of Federal Regulations, Title 42, Section 483.25(c) Mobility. (2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Code of Federal Regulations, Title 42, Section 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 2/19/26, the Department conducted an unannounced visit to the facility to investigate two complaints regarding resident care. The facility failed to notify the physician of Resident 1's changed condition after Resident 1 sustained a fall on 1/31/26, which left Resident 1 with a decline in ability to move in bed, transfer (move from one location to another) from the bed to a wheelchair (a wheeled mobility device, designed as a chair for individuals with limited mobility due to illness, injury, or disability), maintain a standing position, and ambulate (walk) over 50 feet (unit of measurement) while using a front wheeled walker (FWW - a lightweight, four-legged metal frame designed to help people walk with better balance and stability). This failure resulted in Resident 1's left hip fracture (break) going undiagnosed for six days following the unwitnessed fall on 1/31/26, resulting in Resident 1 suffering a significant increase in pain and decline in mobility. A review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility on 1/10/26 with a diagnosis that included bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left hip and vascular dementia (a progressive state of decline in mental abilities). A review of Resident 1's clinical document titled, "Nurses Note," dated 1/31/26, indicated, "Resident 1 had an unwitnessed fall at around 7:30 AM. Resident was found on the floor in his room lying on his left side right next to his bed...Upon assessment, resident reported pain scale of 5/10 [a 1 through 10 numerical pain scale that measures the intensity and impact of pain on daily life: 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 9 = severe pain, and 10 = the worst pain imaginable] on the left site [sic] of the hip ... Painful to touch. Pain was sharp...Notified ... the Medical Doctor [MD]. Order received as following: Norco [a strong pain medication only available with a prescription] ... for moderate to severe pain 4-10/10 [pain medication ordered for pain of 4 out of 10 through 10 out of 10 using the numerical pain scale] PRN [as needed] Q [every] 6hrs [hours]..." A review of Resident 1's clinical document titled, "Order Summary Report," dated 1/1/26 through 1/31/26, indicated Resident 1 had a physician's order dated 1/10/26 for acetaminophen 325 MG (milligrams, unit of measurement) 2 tablets by mouth every 6 hours as needed for a pain score of 1 through 3 (mild pain) and a physician's order dated 1/31/26 for hydrocodone-acetaminophen 5-325 MG (Norco) give 1 tablet orally every 6 hours as needed for a pain score of 4 through 10 (moderate to severe pain) on a 1-10 numerical pain scale. A review of Resident 1's clinical document titled, "MEDICAL NECESSITY-PHYSICIAN FOLLOW-UP VISIT NOTE," dated 2/1/26, indicated, "...Seen and examined today for change of condition related to...recent unwitnessed fall with reported pain ... New order: Hydrocodone-Acetaminophen [Norco] 5/325 mg. give [sic] 1 tablet PO [by mouth] every 6 hours as needed for moderate to severe pain (4-10/10) for 14 days. New Order: X-ray [a diagnostic test that uses electromagnetic waves to indicate the condition of bones] of bilateral [both] hips and pelvis ... Therapy to reassess as indicated..." A review of Resident 1's clinical document titled, "Order Summary," dated 2/1/26 by the MD, indicated, "... Communication Method: Phone ... Order Summary: may have follow up appointment with Radiology department to get an x-ray of both hips and pelvis ..." A review of Resident 1's clinical document titled, "Nurses Note," dated 2/2/26, indicated, "...Pain scale of 4/10 [four out of 10] reported when the resident is being changed or being transferred [moved] to wheelchair..." A review of Resident 1's clinical document titled, "Physical Therapy Treatment Encounter Note(s)," dated 2/2/26, indicated, "...Pt [patient] c/o [complained of] pain 10/10 [the worst pain imaginable] upon movement of LLE [left lower leg]. Pt had a reported fall 1/31/26. Pt assisted x 2 [2 person assist] bed mobility [movement in bed] and proper positioning to prevent skin breakdown [skin tear injuries] and contractures [structural changes to the soft and connective tissues that cause them to stiffen, tighten and contract] ...Pain at Rest Intensity = 0/10 [no pain] Pain with Movement Intensity=10/10 [the worst pain imaginable]..." A review of Resident 1's clinical document titled, "Physical Therapy Treatment Encounter Note(s)," dated 2/3/26, indicated, "...Pt still unable to move LLE without significant pain. Pt able to tolerate sitting in chair with minimal to no movement of LLE...Pain at Rest Intensity=2/10 [mild pain] Pain with Movement Pain Intensity=9/10 [severe pain] ..." A review of Resident 1's clinical document titled, "Physical Therapy Treatment Encounter Note(s)," dated 2/4/26, indicated, "...Pt unable to ambulate. Any movement of LLE increased pain to 9/10 or 10/10. no [sic] exercises done on LLE...Pain at Rest Intensity=2/10 Pain with Movement Pain Intensity =10/10..." A review of Resident 1's clinical document titled, "Physical Therapy Treatment Encounter Note(s)," dated 2/5/26, indicated, "...Pt still having pain on LLE upon gentle ROM [range of motion -the full, maximum distance and direction a joint or body part can normally move]. NWB [non weight bearing- the injured leg must not bear any weight] observed at this time until further examination done... Pain at Rest Intensity 2/10 [mild pain], Pain with Movement Paint intensity = 10/10 [the worst pain imaginable] ..." During a review of Resident 1's clinical record from the [ACUTE CARE HOSPITAL] titled, "XR [x-ray] HIP 2 TWO 3 VIEWS LEFT WO [without] PELVIS," dated 2/6/26, indicated Resident 1 had a new left hip fracture. A review of Resident 1's clinical document titled, "Physical Therapy Discharge Summary," dated 1/12/26 through 2/6/26, indicated the following assessment dates and functional level of Resident 1 from the start of physical therapy on 1/12/26 to Resident 1's discharge to [ACUTE CARE HOSPITAL] on 2/6/26. "...Bed Mobility: 1/12/2026 Baseline Minimum Assistance Min (A) [patient can perform 75% of the mobility task while the one therapist assists with 25%] required with verbal cues [verbal cues to a resident to help them complete a task] 35% of the time, 2/1/2026 Stand by Assistance (SBA) [assistance of one therapist within arm's reach to ensure safety during the tasks, without touching or helping the patient] required with occasional verbal cues, 2/6/2026 Maximum Assistance (Max A) [assistance of one therapist required to perform approximately 75% of the work of a mobility task while the patient performs 25% of the work] with 75% verbal cueing... Transfers: 1/12/2026 Baseline Moderate Assistance Mod (A) [a person can do about 50%-75% of a task (like bathing, dressing, or walking) on their own but requires significant, hands-on help from a caregiver or therapist for the other 25%-50%] with 35% verbal cueing, 2/1/2026 Contact Guard Assist (CGA) [assistance of one therapist who has one or two hands on the patient's body but provides no other assistance to perform the functional mobility task. The contact is made to help steady the patient's body or help with balance] with 10% verbal cueing, 2/6/2026 Max A x 2 with 75% verbal cueing... -Ambulation Distance on Level Surfaces: 1/12/2026 Baseline 20 feet Mod (A), 50% verbal cueing, 2/1/2026 50 feet Min (A) 75% verbal cueing, 2/6/2026 NA [not applicable], DNT [did not attempt due to safety concern] ...Patient was discharged from PT when discharged to the acute on 2/6/2026..." A review of Resident 1's clinical document titled, "Occupational Therapy Treatment Encounter Note(s)," dated 2/2/26, indicated "...Patient approached for scheduled OT [Occupational Therapy, a form of therapy that focuses on dressing, eating, and grooming] session patient reported 10/10 [severe] pain and refused to get out of bed. OT attempted to initiate bed mobility tasks to assess functional tolerance and promote participation; however, patient stated, 'please No' and declined all therapeutic activity due to pain. Nursing staff confirmed patient experienced a fall over the weekend, which may be contributing to increased pain and decreased activity tolerance. OT assisted CNA with brief [adult diapers that collects urine and stool] change to ensure patients safety, hygiene, and skin integrity. Patient remained verbally expressive of pain throughout encounter and was unable to safely participation skilled OT services at this time due to medical limitations..." A review of Resident 1's clinical document titled, "Occupational Therapy Treatment Encounter Note(s)," dated 2/3/26, indicated, "...Patient reported LE [lower extremity - leg] pain and declined any weight bearing activities. LE pain is impacting ability to safely perform transfers and is limiting OT sessions..." A review of Resident 1's clinical document titled, "Occupational Therapy Treatment Encounter Note(s)," dated 2/4/26, indicated, "...LLE [left lower extremity] pain is impacting ability to safely perform transfers, patient states, '10/10 pain' this is limiting OT sessions to in chair adls [activities of daily living- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves] and UE [upper extremity] strengthing [sic]..." A review of Resident 1's clinical document titled, "Occupational Therapy Treatment Encounter Note(s)," dated 2/5/26, indicated, "...LLE pain continues to impact patients [sic] ability to safely perform transfers, toileting [using the bathroom to void or stool] and LE exercises. patient [sic] states, '10/10 pain' with rolling and transfers this is limiting OT sessions to in chair adls and UE strengthing [sic]..." A review of Resident 1's clinical document titled, "Occupational Therapy Discharge Summary," dated 1/12/26 through 2/5/26, indicated the following assessment dates and functional level of Resident 1 from the start of occupational therapy on 1/12/26 to Resident 1's discharge to [ACUTE CARE HOSPITAL] on 2/6/26. "...Functional Mobility during ADLS: 1/12/2026 Baseline Mod (A) [patient does 50-75% of the work, and the Occupational Therapist (OT) assists with the remainder] with 35% verbal cueing, 2/1/2026 Min (A) [patient does 75% if the work, and OT does 25% or less of the work] with 20% verbal cueing, 2/5/2026 Max (A) [patient can perform 25-50% of the task and the remainder is completed by OT] with 20% verbal cueing... Dynamic Standing Balance [the ability to maintain an upright, stable posture while moving or shifting one's center of gravity outside the base of support]: 1/12/2026 Baseline Poor + Mod A [resident has significant, but not total, impairment requiring moderate physical assistance to maintain balance and perform tasks safely] and UE [upper extremity] support to stand and reach ipsilaterally [same side] w/o [without] LOB [loss of balance]; unable to weight shift, 2/1/2026 Fair - Min (A) or UE support to stand w/o LOB & to reach ipsilaterally; unable to weight shift, 2/5/2026 Poor (Max (A) & UE support to maintain standing balance and reach ipsilaterally; unable to weight shift...Patient was discharged from OT when sent to the [ACUTE CARE HOSPITAL] on 2/6/2026..." A review of Resident 1's clinical documents, titled "MEDICATION ADMINISTRATION RECORD" (MAR- a document that indicates medications ordered, held, or discontinued along with pertinent lab values that are used for discernment in medicati