Kit Carson Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Kit Carson Nursing & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 30, 2026

  Based on interview and record review, the facility failed to provide quality care and services as per professional standards of practice for one of four sampled residents (Resident 4), when:1a. Facility staff did not assess, notify physician, and treated Resident 4 when she had abdominal pain and did not have a bowel movement for 3 days from 12/14/25 to 12/16/25, from 12/20/25 to 12/22/25, and for 6 days from 12/30/25 to 1/4/26 and had multiple bowel movements of foul odor,b. Licensed Nurses did not completely assess, address, and notify physician of Resident 4's change in condition of abdominal tenderness, increased weakness, and progressive decline in ADL (Activities of Daily Living) when Resident 4 was no longer able to shower herself on 2/5/26, dress herself on 2/6/26 and transfer… […]

• Actual harm, isolatedF684Mar 10, 2026

  Based on interview and record review, the facility failed to provide quality of care (each resident must receive the necessary care and services to attain or maintain the highest practicable physical well-being) in accordance with professional standards of practice for one of three sampled residents (Resident 1) when,1.The facility staff did not implement in a timely manner the Wound (tissue injury) Doctor's (WD) verbal recommendation on [DATE] to transfer Resident 1 to an acute care hospital for a higher level of care to treat a worsening venous ulcer wound (shallow, slow-healing, or chronic [long term] wounds) on Resident 1's right leg and/or initiate in a timely manner a verbal order on [DATE] from the Medical Director (MD) to arrange a consultation with a vascular surgeon (a highly… […]

• Actual harm, isolatedF580Feb 19, 2026

  Based on observation, interview, and record review the facility failed to notify the physician of a significant change in condition for one of four sampled residents (Resident 1) when,1.The facility did not notify Resident 1's physician after Resident 1 had consistent moderate to severe hip pain and decreased mobility following a fall on 1/31/26. This failure resulted in Resident 1's left hip fracture (break) going undiagnosed for six days resulting in Resident 1 experiencing pain and a decline in the 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… […]

• Actual harm, isolatedF689Mar 28, 2025

  Based on interview and record review the facility failed to use appropriate and safe transfer methods according to resident's care needs for one of three sampled residents (Resident 2) when, Certified Nursing Assistant (CNA) 2 transferred Resident 2 from the shower chair (a waterproof chair on wheels used to transport residents to and from the shower room) to her bed using a bear-hug (a transfer technique where a caregiver wraps their arms around the individual under the armpits, like a bear hug, to assist in standing and moving them) and one person assist. […]

• Actual harm, isolatedF600Sep 12, 2024

  Based on observation, interview, and record review, the facility failed to provide a safe environment and the supervision needed to ensure one of 24 sampled residents (Resident 39) was protected from physical abuse when another resident (Resident 79), who had a history of severe mental illness and violent behaviors, entered Resident 39's room and struck him in the face multiple times. This failure resulted in Resident 39 sustaining facial bruising and redness, a cut lower lip, overall head pain, and feelings of fearfulness. Findings: A review of Resident 39's clinical record titled. […]