Health inspection·June 10, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure an environment free of accidents or hazards for two of three sampled residents (Resident 2 and Resident 3) when: Residents Affected - Some 1. Resident 2 ' s and Resident 3 ' s Wander Guard devices (a monitoring device used to alert staff of a resident leaving the premises) were not checked for placement and functionality each shift (3 shifts in a 24 hour period) each day; and, 2. Resident 2 ' s and Resident 3 ' s Elopement (an act or instance when a cognitively impaired person leaves a safe area or premises unsupervised and undetected) Risk Assessments were not completed quarterly; and, 3. Resident 3 exited the facility on 6/4/25 and was missing for an unknown period of time before staff found her in the street on 6/4/25; and, 4. Resident 3 was not reassessed for Elopement Risk after she exited the facility on 6/4/25; and, 5. Weekly checks for the facility Wander Guard systems functionality were not documented by the Maintenance Supervisor. These failures had the potential to result in Resident 2 and Resident 3 sustaining life-threatening injuries from elopement. Findings: 1. a. A review of Resident 2 ' s admission Record indicated that Resident 2 was admitted to the facility in 2024 with diagnoses which included Alzheimer ' s Disease (the most common cause of dementia — a gradual decline in memory, thinking, behavior and social skills which causes the brain to shrink and brain cells to eventually die. These changes affect a person's ability to function). A review of Resident 2 ' s Physician Order Summary dated 4/23/25, the Physician Order Summary indicated, .May use wander guard for risk of elopement three times a day . A review of Resident 2 ' s Care Plan Report dated 12/7/24, the Care Plan Report indicated, .Focus .Resident is at risk for elopement .Date initiated: 12/7/24 .Goal: Resident will not leave facility unsupervised .Interventions: May use wander guard for precautions. Check placement and functionality of wander guard q (every) shift . Page 1 of 6 056198 056198 06/10/2025 Kit Carson Nursing & Rehabilitation Center 811 Court Street Jackson, CA 95642

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 2 ' s Medication Administration Record (MAR, a document listing medications and monitoring parameters) dated 5/2025, the MAR indicated that Resident 2 ' s Wander Guard device was not checked for placement and functionality on 5/21/25 at 4PM, or on 5/30/25 at 4PM. A review of Resident 2 ' s MAR dated 6/2025, the MAR indicated that Resident 2 ' s Wander Gard device was not checked for placement and functionality on 6/5/25 at 4PM or on 6/8/25 at 4PM. During an interview on 6/10/25 at 12:35 p.m., with the facility Director of Nursing (DON), the DON stated that her expectation was that the Licensed Nurses (LN) checked the placement of the residents ' Wander Gard devices and documented the Wander Gard device checks in the residents ' electronic medical records (EMR, a digital version of a resident ' s medical history) every shift every day. The DON stated that the LNs notified the Maintenance Supervisor if the Wander Gard devices needed batteries or if they were not working properly. During an interview on 6/10/25 at 1:20 p.m. with LN 2 at the Station 2 nurses ' station, LN 2 confirmed that Resident 2 had a Wander Guard device on his ankle. LN 2 stated that Resident 2 had good days and bad days where he wandered in his wheelchair. During a concurrent interview and record review of Resident 2 ' s MAR for 5/2025 and 6/2025 with the DON on 6/10/25 at 2:55 p.m., the DON stated that her expectation was that LNs documented the Wander Guard device checks each shift, each day, for residents with a Wander Guard device. The DON confirmed that Resident 2 did not have documented Wander Guard device checks each shift each day on 5/21/25, 5/30/25, 6/5/25, and 6/8/25. The DON stated that LNs should have documented Wander Gard device checks for Resident 2 each shift, each day. The DON stated that the risk was elopement. The DON stated that the facility policy was not followed. b. A review of Resident 3 ' s admission Record indicated that Resident 3 was admitted to the facility in 2024 with diagnoses which included Vascular Dementia (impairment of brain function caused by impaired blood flow to the brain, including loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 3 ' s Physician Order Summary, dated 4/25/24, indicated, .May use wander guard for precautions. Check placement and functionality of wander guard .every shift . A review of Resident 3 ' s Care Plan Report dated 4/6/24 indicated, .Focus: .episodes of wandering .leaves unit r/t (related to) impaired cognition, poor judgment .Goal: Resident will remain safe within the facility daily .Interventions: .May use wander guard for precautions. Check placement and functionality of wander guard q (every) shift . A review of Resident 3 ' s MAR dated 5/2025, the MAR indicated that Resident 3 ' s Wander Guard device was not checked on 5/2/25 PM shift, 5/18/25 PM shift, or on 5/29/25 AM shift. A review of Resident 3 ' s MAR dated 6/2025, the MAR indicated that Resident 3 ' s Wander Guard device was not checked on 6/4/25 AM shift, 6/8/25 AM shift, 6/8/25 PM shift, 6/9/25 AM shift, or on 6/9/25 PM shift. During an interview with LN 1 on 6/10/25 at 11:35 a.m., LN 1 stated that Resident 3 was currently at an eye doctor appointment but that Resident 3 had a Wander Guard device on her right ankle. 056198 Page 2 of 6 056198 06/10/2025 Kit Carson Nursing & Rehabilitation Center 811 Court Street Jackson, CA 95642

F 0689 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review of Resident 3 ' s MAR for 5/2025 and 6/2025 with the DON on 6/10/25 at 2:55 p.m., the DON confirmed that Resident 3 did not have documented Wander Guard device checks every shift on 5/2/25, 5/18/25, 5/29/25, 6/4/25, 6/8/25 and 6/9/25. The DON stated that LNs should have documented Wander Guard device checks each shift, each day, for Resident 3. The DON stated that the risk was elopement. The DON stated that the facility policy was not followed. Residents Affected - Some 2. a. During a review of Resident 2 ' s Elopement Risk Assessment dated 12/7/24, the Elopement Risk Assessment indicated, .Observation date: 12/07/2024 .Description: Elopement Risk Assessment .1. Is the resident cognitively impaired with poor decision-making skills? Yes .2. Does the resident have a pertinent of .Alzheimer ' s .? Yes .7. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near exit door? Yes .8. Does the resident wander .? Yes .Summary of Assessment A. Is the resident at risk for Elopement at this time? Did you answer YES to questions .8 .? If you answered YES, the resident is AT HIGH RISK FOR ELOPEMENT. During a concurrent interview and record review of Resident 2 ' s Elopement Risk Assessment with the facility DON on 6/10/25 at 2:17 p.m., the DON stated that her expectation was that residents were assessed for elopement risk upon admission, quarterly, and annually. The DON stated that the residents were also reassessed if the residents eloped. The DON stated that Resident 2 should have been assessed for elopement risk upon admission, quarterly, and annually as he wandered. The DON confirmed that Resident 2 was assessed for elopement risk on 12/7/24. The DON confirmed that no other elopement risk assessments were completed for Resident 2 after 12/7/24. The DON acknowledged that the LNs should have assessed Resident 2 for elopement risk quarterly (next on 3/2025 and 6/2025). The DON confirmed that the facility policy was not followed. b. A review of Resident 3 ' s Elopement Risk Assessment dated 1/6/25, indicated, .Observation date: 01/06/2025 .Description: Quarterly .1. Is the resident cognitively impaired with poor decision-making skills .? Yes .2. Does the resident have a pertinent of Dementia .Yes .3. Does the resident ambulate independently with or without the use of an assistive device (including a wheelchair?) Yes .4. Does the resident have a history of elopement while at home? Yes .5. Does the resident have a history of leaving the facility without need of supervision? Yes .6. Does the resident have a history of leaving the facility without informing staff? Yes .8. Does the resident wander .? Yes .9. Is the wandering behavior a pattern or routine tied to the resident ' s past .? Yes .11. Does the resident receive any medication that increases restlessness and agitation? Yes .13. Has the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to? Yes .II. Summary of Assessment A. Is the resident at risk for Elopement at this time? . Did you answer YES to question 4, 6, 8 or 13? If you answered YES, the resident is AT HIGH RISK FOR ELOPEMENT.B. Additional Comments .Wander Guard in use daily . During a concurrent interview and record review of Resident 3 ' s Elopement Risk Assessment with the facility DON on 6/10/25 at 2:17 p.m., the DON stated that her expectation was that residents were assessed for elopement risk upon admission, quarterly, and annually. The DON stated that the residents were also reassessed if the residents eloped. The DON stated that Resident 3 should have been assessed for elopement risk upon admission, quarterly, and annually as she wandered. The DON confirmed that Resident 3 was assessed for elopement risk on 1/6/25. The DON confirmed that no other elopement risk assessments were documented for Resident 3 since 1/6/25. The DON acknowledged that the LNs should have assessed Resident 3 for elopement risk quarterly (next on 4/2025). The DON stated that the risk was elopement. The DON confirmed that the facility policy was not followed. 056198 Page 3 of 6 056198 06/10/2025 Kit Carson Nursing & Rehabilitation Center 811 Court Street Jackson, CA 95642

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. During a concurrent observation and interview on 6/10/25 at 12:30 p.m. with Resident 3 and a Student Nursing Assistant (SNA) in the hallway near Resident 3 ' s room, Resident 3 stated that she did not feel well. Resident 3 repeated that she did not feel well when asked questions. Resident 3 was observed in her wheelchair with a Wander Guard device on her right ankle. The SNA stated that Resident 3 wandered in the hallway a lot, so she stayed with her. The SNA stated that Resident 3 went out of the facility exit door last week. The SNA stated that she was on Station 2 last week, and she heard the Wander Guard alarm. The SNA stated that the staff on duty that day told her that Resident 3 went out the exit door on Station I. The SNA stated that she did not know how long Resident 3 was outside the facility or when Resident 3 was brought back to the facility. During an interview with LN 1 on 6/10/25 at 1:20 p.m., LN 1 stated that last week the Wander Guard alarm went off at Station 1, but she did not know if a resident left the building because she worked at Station 2. During an interview with the Admitting Clerk (Admit) on 6/10/25 at 1:25 p.m., the Admit stated that she also was the receptionist. The Admit stated that Resident 3 left the facility, and the Dietary Supervisor brought her back into the facility last week. The Admit stated that she did not know when Resident 3 left the facility or how long Resident 3 was outside of the facility. During an interview on 6/10/25 at 1:30 p.m. with the Dietary Supervisor (DS), the DS stated that he worked at the facility for six weeks. The DS stated that he left the faciity on 6/4/25 at the end of his shift and went to his car in the parking lot outside the facility. The DS stated that he saw Resident 3 in her wheelchair in the street at around 2:40 p.m. and that he brought Resident 3 back into the facility. The DS stated that he did not know how Resident 3 got out of the facility. The DS stated that he did not know how long Resident 3 was outside of the facility. The DS stated that he did not hear any alarms when he left the facility to go to his car in the parking lot. The DS stated that he reported the incident to the Director of Staff Development (DSD) after he brought Resident 3 back into the facility. The DS stated that he spoke with the ADM and the DON the next day and they were aware of the incident. During an interview on 6/10/25 at 2:06 p.m. with LN 3 at Station 1, LN 3 stated that Resident 3 was quick. LN 3 stated that she was not sure how Resident 3 got out of the facility. LN 3 stated that Resident 3 may have left the facility with visitors. During an interview on 6/10/25 at 2:10 p.m. with Certified Nursing Assistant (CNA) 1, the CNA 1 stated Resident 3 tried to get out of the facility all day long every day. During a concurrent interview and record review of Resident 3 ' s EMR with the DON on 6/10/25 at 2:17 p.m., the DON confirmed that Resident 3 wandered. The DON stated that the incident regarding Resident 3 leaving the facility was reported to her and the ADM by the DSD. The DON stated that she did not know when Resident 3 left the facility. The DON stated that she did not know how long Resident 3 was outside of the facility before she was found by the DS. The DON stated that she was told that Resident 3 was not injured. The DON stated that she was told that the Wander Guard alarm sounded, and staff later found Resident 3 outside. The DON confirmed that there was no change in condition documentation by the LN on duty, no care plan update, no SBAR (a communication tool for sharing information with teams and stands for Situation, Background, Assessment, and Recommendation or Requests) documentation by the LN on duty, and no progress note documentation by the LN on duty regarding Resident 3 ' s elopement on 6/4/25. The DON 056198 Page 4 of 6 056198 06/10/2025 Kit Carson Nursing & Rehabilitation Center 811 Court Street Jackson, CA 95642

F 0689 confirmed that the facility policy was not followed. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 6/10/25 at 2:41 p.m. with the DSD, the DSD confirmed that the DS reported to her that he found Resident 3 outside of the facility in the street on 6/4/25 after he brought her back inside. The DSD stated that she notified the ADM and the DON regarding the incident. The DSD stated that she was in her office and did not hear the Wander Guard alarm that day. The DSD stated that she did not know how long Resident 3 was outside the facility. The DSD stated that she did not document in Resident 3 ' s EMR regarding the incident. Residents Affected - Some 4. During a concurrent interview and record review of Resident 3 ' s elopement risk assessments on 6/10/25 at 2:17 p.m. with the DON, the DON stated that her expectation was that the residents were reassessed if the residents eloped. The DON confirmed that Resident 3 was assessed for elopement risk on 1/6/25. The DON confirmed that Resident 3 was not reassessed for elopement risk after the incident on 6/4/25. The DON stated that the LN on duty should have documented an elopement risk reassessment in Resident 3 ' s EMR after the incident on 6/4/25. The DON confirmed that the facility policy was not followed. 5. During a concurrent interview and record review on 6/10/25 at 11:25 a.m. with the Maintenance Supervisor (MS), the MS stated that there were Wander Guard alarms on the facility exit doors in Station I, Station 2, and the Kitchen. The MS stated that the Wander Guard exit door alarms were checked weekly for functionality. The MS stated that he took the Wander Guard sensor to each exit door to see if the alarm triggered in order to test the functionality of the system. When asked, the MS stated that he did not keep a log of the weekly Wander Guard alarm checks. The MS stated that he reported the results of the Wander Guard weekly checks verbally at the meetings with the facility directors and the ADM. A review of a facility policy and procedure (P&P) titled, Safety of the Residents, Staff, and Visitors, revised April 2025, the P&P indicated, .Policy .To ensure that all possible measures be taken in order to safeguard residents, staff and visitors .Procedure .3. Exit doors are alarmed and/or Wanderguard [sp] which can be used as needed to make sure if any resident goes out unaccompanied by staff or resident ' s representative and/or not self-responsible, the staff will be alerted when he/she leaves the facility .The staff of the facility will be aware of all the safety measures and their implementation . A review of a facility P&P titled, Change of Condition, revised April 2025, the P&P indicated, .Routine Medical Change .Routine changes are a minor change in physical and mental behavior .6. Document resident change of condition and response in nursing progress notes, on Twenty-Four Hour Report and update resident Care Plan .7 .Documentation will include time and response .Follow Up .1. The licensed nurse responsible for the resident will continue assessment and documentation every shift for seventy-two (72) hours or until condition has stable [sp] . A review of a facility P&P titled, Policy and Procedure on Wanderguard, revised April 2025, the P&P indicated, .a wanderguard equipment is installed to have monitoring to residents who have tendency to wander out from the facility aimlessly .All residents who are assessed to be aimlessly wandering .without resident/resident representative consent and MD (physician) order will be wearing a wanderguard bracelet .Once resident with wanderguard leaves the facility, the wanderguard alarm will be activated. The staff at this time will be alerted that the resident is trying to go out from the facility. A staff will immediately proceed to the area where the alarm is activated to assist resident by redirecting him/her to proper direction . 056198 Page 5 of 6 056198 06/10/2025 Kit Carson Nursing & Rehabilitation Center 811 Court Street Jackson, CA 95642

F 0689 Level of Harm - Minimal harm or potential for actual harm A review of the Manufacturer ' s document titled, [Brand Name Monitoring Device], provided by the manufacturer, published October 20, 2021, indicated, .Best practice: It is recommended to have the .battery checked at least once a week .Weekly testing and maintenance of this product, as described in the Product documentation, is essential to verify the system is operating correctly . Residents Affected - Some 056198 Page 6 of 6