Health inspection·August 20, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure one of six residents (Resident 1) with an indwelling catheter (catheter; a thin, flexible tube inserted into the bladder to drain urine) received catheter care and services when:1. Resident 1's suprapubic catheter (a temporary or permanent drainage route for urine, through a small incision in the abdominal wall, from the bladder directly into a collection bag) was not changed as ordered by the physician;2. Resident 1's suprapubic catheter was not consistently monitored following suprapubic catheter changes; and3. Care plans (a personalized, written document that details a resident's specific health and personal care needs, goals, and interventions) were not in place for Resident 1's catheter changes and Resident 1's urinary tract infection (UTI - A condition in which bacteria invade and grow in the urinary tract) in June of 2025.These failures could have been the cause of Resident 1's UTI and 10 out of 10 pain, (pain scale of 1 through10; with 10 being the worst pain) which resulted in Resident 1 being transferred to the emergency room for an evaluation.1. During a review of Resident 1's clinical document titled, admission RECORD, (contains Resident 1's clinical and demographic data) indicated Resident 1 was admitted to the facility with diagnoses which included obstructive and reflux uropathy (a condition where the urinary tract becomes blocked and prevents the normal flow of urine). A review of Resident 1's clinical document titled, Order Summary Report, dated 4/17/25, indicated, . Routine Monthly Suprapubic Cath [catheter] changes at [local hospital] once a month starting on the 20th and ending on the 27th of every month . Order Date . 4/17/25 . During a concurrent interview and record review on 8/20/25, at 2:11 PM, with the Director of Nursing (DON), Resident 1's record titled, Progress Notes, dated 4/26/25 through 8/8/25 were reviewed. The DON confirmed Resident 1's suprapubic catheter changes were done every other month, not monthly as ordered. The DON explained the importance of completing the suprapubic catheter change was to ensure the physician orders were carried out. The DON further stated there was a risk for Resident 1 to acquire an infection and experience pain. A review of the facility policy titled, Physician's Orders, revised 7/12, indicated, . Physician's orders shall be carried out as prescribed . 2. A review of Resident 1's clinical document titled, Progress Notes, dated 4/26/25 through 4/28/25, 6/21/25 through 6/24/25, and 8/5/25 through 8/8/25 indicated Resident 1's post catheter change monitoring was not done for five out of nine opportunities for April of 2025, six out of nine opportunities for June of 2025, and three out of nine opportunities for August of 2025 as follows: 4/26/25 PM shift (2 PM through 10 PM); monitoring not noted 4/27/25 AM shift (6 AM through 2 PM); monitoring not noted 4/27/25 NOC shift (10 PM through 6 AM); monitoring not noted 4/28/25 AM shift; monitoring not noted 4/29/25 AM shift; monitoring not noted 6/21/25 PM shift; monitoring not noted 6/21/25 NOC shift; monitoring not noted 6/22/25 AM shift; monitoring not noted 6/22/25 NOC shift; monitoring not noted 6/23/25 AM shift; Resident 1 sent to emergency for 10 out of 10 pain 6/23/25 NOC shift; monitoring not noted 6/24/25 AM shift; monitoring not noted 8/5/25 NOC shift; Page 1 of 2 056198 056198 08/20/2025 Kit Carson Nursing & Rehabilitation Center 811 Court Street Jackson, CA 95642

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monitoring not noted 8/7/25 AM shift; monitoring not noted 8/7/25 NOC shift; monitoring not noted A review of Resident 1's clinical document titled Progress Notes, dated 6/23/35, indicated, . Resident [1] sent out to [local hospital] via ambulance on 6/23/25 @ [at] 1317 [1:17 PM] for c/o [complaint of] 10/10 [assessment tool for pain - pain is rated 1 through 10 with 10 being the worst pain] pain in SP [suprapubic] catheter site. Catheter was just replaced at [local hospital] on 6/21/25. Resistance was noted when flushing [the process of rinsing the tube with sterile water or saline to clear out any blockages] and no output [urine] was noted during flush. Resident [1] requested to be sent out to ED [emergency department]. A review of Resident 1's clinical document titled, [Outside hospital] ED Provider Notes, dated 6/23/25, indicated, . UA [urinalysis urine test that checks for signs of infection] suggests catheter-associated UTI [urinary tract infection] . Given UA consistent with UTI and prior culture [a laboratory test that checks a urine sample for bacteria, or other germs that can cause a UTI] history, empiric [brand name antibiotic] [antibiotic used to treat suspected infection] prescribed . During a concurrent interview and record review on 8/20/25 at 2:11 PM, with the DON, Resident 1's record titled, Progress Notes, dated 4/26/25 through 8/8/25 were reviewed. The DON confirmed Resident 1's suprapubic catheter monitoring were not consistently completed for the 72-hour duration as required on the above dates and shifts. The DON stated monitoring the suprapubic catheter for 72 hours after it was changed was to ensure if there was a change in Resident 1's condition, nursing could coordinate with the physician in case there were additional changes or orders that needed to be carried out. The DON further stated there was a risk for Resident 1 to acquire an infection and was at risk for pain. A review of the facility policy titled, Change of Condition, revised 7/24, indicated, . Routine Medical Change . All symptoms and unusual signs will be communicated to the physician promptly . Document resident change of condition and response in nursing progress notes . Follow-up . The licensed nurse responsible for the resident will continue assessment and documentation every shift for seventy-two (72) hours . 3. A review of Resident 1's clinical document titled, Care Plan Report, undated, indicated there was not a care plan in place for Resident 1's suprapubic catheter changes or for Resident 1's UTI from 6/23/25. During a concurrent interview and record review on 8/20/25 at 2:11 PM, Resident 1's care plans were reviewed with the DON. The DON confirmed Resident 1's care plans had not been updated to include Resident 1's UTI on 6/23/25 and it should have been. The DON further stated there was not a care plan in place for catheter changes and there should have been. The DON stated the importance of having the care plans in place was to ensure licensed nurses had a guide on how to take care of the Resident 1's suprapubic catheter. A review of the facility policy and procedure titled, Policy and Procedure - Care Plan, revised 9/2024, indicated, . A care plan is the summation of the resident concerns, goals, approaches and interventions in order to meet the goals and help minimize if not totally eradicate residents' problems . the evidence of a care plan that has been reviewed should include but not be limited to the new interventions that have been added in addition to the current ones . 056198 Page 2 of 2