Eldorado Rehab & Healthcare

Inspectors wroteBased on interview, and record review, the facility failed to ensure staff treated a resident with dignity and respect by not interacting in a manner that enhanced self-worth and quality of life for 1 (R1) of 4 residents reviewed for Resident Rights in the sample of 4. Findings Include: R1's, admission Record, documented R1 admitted to the facility on [DATE]. R1's diagnoses listed include cerebral ischemia, other speech and language deficits following cerebral infarction, cognitive communication deficit, aphasia, dysphonia, Parkinsonism, weakness, and transient cerebral ischemic attack. R1's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 14, indicating R1 is cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of staff to resident verbal abuse timely to the State Survey Agency and local law enforcement for 1 (R1) of 4 residents reviewed for abuse in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse for 1 (R1) of 4 residents reviewed for abuse in the sample of 4.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide nutritional supplements as ordered for 2 of 3 residents (R1 and R13) reviewed for nutrition in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person centered Care Plan for 1 (R43) of 19 residents reviewed for comprehensive care plans in a sample of 33.

Inspectors wrote3. R7's admission Record documented R7 was admitted to the facility on [DATE] and include diagnoses of muscle weakness (generalized), unsteadiness on feet, and other reduced mobility. R7's MDS dated [DATE] documented a BIMS score of 14, indicating R7 was cognitively intact. In the section titled Functional Abilities under Self-Care, the MDS documented R7 requires substantial/maximal assist for showering/bathing, meaning the helper does more than half the effort . On 04/14/25 02:25PM, R7's hair appeared greasy and unkempt/uncombed. R7 stated We don't get our showers on time. We often only get a shower once a week. On 04/16/25 at 10:05 AM, R7 stated that her shower days are scheduled for Mondays and Thursdays. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed rails/enablers were installed in accordance with manufacturer's recommendations and specifications for 1 (R7) of 1 resident reviewed for bed rails in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to develop a plan for appropriate treatment and services for a resident with dementia for 1 (R43) of 19 residents reviewed for dementia care in a sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered safely for 2 of 5 residents (R2 and R3) reviewed for medication administration in sample of 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep resident care areas and equipment clean and in a good state of repair. This has the potential to affect all 60 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that food items in the kitchen were properly stored/labeled and equipment was properly cleaned and maintained. This failure has the potential to affect all 60 residents residing in the facility. The Finings Include: During the initial tour of the facility on 2/6/24 at 8:40 AM the following concerns were noted: 1. A one gallon container of milk was in the refrigerator without a lid and not dated/labeled. 2. An open bag of shredded white and yellow cheese was found in the reach in refrigerator opened and not dated. The white shredded cheese was not sealed open to air in original bag. 3. A tray of drinks not labeled, not dated and uncovered were found in the reach in refrigerator. V40 (Corporate Director of Culinary Services) stated that they are drinks for the day for the residents. 4. [...]

Inspectors wroteBased on record review and interview the facility failed to maintain documentation of holding quarterly Quality Assurance and Performance Improvement meetings (QAPI). This has the potential to affect all 60 residents residing in the facility. The Findings Include: During the investigation and review of facility records no evidence of quarterly QAPI meeting attendance or meeting information was found or produced by the facility. On 2/9/24 at 2:30 PM, V1 (Administrator) stated that he is not able to find any documentation of minutes or attendance sheets prior to January 2024 for the facility's quarterly QAPI meeting. V1 went on to state that he started his employment at this facility in January 2024 and no QA information is able to be accessed prior to that. The Long Term Care Facility application for Medicare and Medicaid dated 2/6/24, documents 60 residents reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities that met resident goals and preferences for five (R7, R13, R14, R26, and R27) of five residents reviewed for activities out of a sample of 40.

Inspectors wroteBased on interview and record review the facility failed to provide person-centered care plan meetings for 1 (R11) of 17 residents reviewed for care planning in a sample of 40. Findings Include: On 2/8/2024 at 9:15 AM, R11 was alert and oriented and stated she has never been invited to a care plan meeting, verbally or in writing. R11 stated, being here almost 3 years and have not been to a meeting, and I do not have a primary medical representative. R11's electronic medical record care plan meeting for quarterly and annual conferences documents that care plan letters were mailed to the patient medical representative with no response. On 02/08/24 at 08:49 AM, V7 (Care Plan/ Minimum Data Set Coordinator) stated, R11 was verbally notified of care plan meetings but nothing was given to R11 on paper, but R11 was reminded of the date and time of meetings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide unconflicted lunch meal and smoking schedules for one resident (R21) of 17 residents reviewed for accommodation of need in the sample of 40.

Inspectors wroteBased on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for one (R58) of one residents reviewed for advanced directives in the sample of 40. Findings Include: R58's Face Sheet documented an admission date to the facility as [DATE]. This document also listed R58's diagnoses including, but not limited to: Acute kidney failure, Dysphagia, Parkinson's disorder without dyskinesia. R58's POLST form, scanned into R58's Electronic Health Record, with a [DATE] signature date by R58, documented a Do Not Resuscitate status. Review of the Advanced Directive tab, as well as the informational screen heading listed in R58's Electronic Record documented R58's status as being attempt CPR (Cardiopulmonary Resuscitation). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and assess adaptive equipment in order to ensure safety and freedom for normal movement for one (R24) of one residents reviewed for physical restraints in the sample of 40. The Findings Include: Review of R24's Face Sheet documents an admission date to the facility as 6/1/22 and includes the diagnosis other reduced mobility, major depressive disorder, spinal stenosis, sciatica, and anxiety disorder. R24's current month of February 2024 Physician Orders does not have an order for the use of a self-releasing seatbelt. R24's Annual Minimum Data Set (MDS) with assessment reference date as 1/12/2024 documents a Brief Interview for Mental Status score of 3, indicating significant cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) coding for one (R59) of 17 reviewed for Minimum Data Sets in the sample of 40. Findings Include: R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family member/Power of Attorney/POA) and V22 (Family member). R59's (Name of town) Primary Care record found in R59's Electronic Health Record, documented a visit on 12/7/23 with a chief complaint being to establish care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide individualized plan of care revisions to meet the needs for one (R59) of 17 residents reviewed for care plans in the sample of 40. Findings Include: R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family Member/Power of Attorney/POA) and V22 (Family Member). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to improve or maintain Range of Motion status and functioning for one (R11) of 17 residents reviewed for Range of Motion in the sample of 40. Findings Include: The Resident Profile section of R11's Electronic Record documents an admission date to the facility of 8/20/21 with diagnoses listed but not limited to type 2 diabetes mellitus, cerebral infraction, unspecified, Hemiplegia, unspecified affecting left nondominant side, hyperkalemia, history of falls, weakness. On 2/06/24 09:26, R11 was observed with a brace to the left lower extremity. R11 stated she had a stroke in 2011. R11 stated, aides do not do any range of motion program, other than 2 times a week when in the shower. The certified nursing assistants will move left hand fingers to clean hand. [...]

Inspectors wroteBased Based on observation, interview, and record review, the facility failed to ensure residents at risk for elopement were accurately assessed and incidents of elopement were appropriately identified and thoroughly investigated for 2 (R59 and R24) of 6 reviewed for accidents and supervision in the sample of 40. This failure resulted in R59, who has a diagnosis of dementia with severe cognitive impairment, eloping from the facility on 12/29/23. Findings Include: 1. R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide aseptic catheter care for one resident with a history of Urinary Tract Infections (R9) of three residents reviewed for catheters in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a residents protein of choice for one resident with weight loss (R7) of four residents reviewed for weight loss in the sample of 40.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents medication regimens were free from unnecessary medication for three (R18, R50 R24) of five residents reviewed for unnecessary medications in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide therapeutic diets per physician's orders for two (R18, R48) residents of four residents reviewed for therapeutic diets in the sample of 40.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that residents had alternative meal options similar or equivalent nutritive value of the main meal selection for three of three residents (R10, R11 and R46) reviewed for meal alternatives in a sample of 40. The Findings Include: On 2/6/24 at 11:00 AM, V3 (Cook/Dietary Manger) stated that he did not have an alternate made today, but that he usually just makes a grilled cheese, peanut butter sandwich or turkey sandwich if the residents do not like what they have on the menu. V3 stated there is not a planned alternate meal option and he just uses what is quick and available. V3 stated that the steam table today for lunch would have the following: Fiesta chicken (regular, mechanical soft, and pureed), Mexican rice (regular and pureed), elote corn and creamed corn, breadstick/bread, and snickerdoodle cookie. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify and systematically investigate an adverse event as part of their Quality Assurance and Performance Improvement (QAPI) meetings/plan for 1 (R59) of 17 residents reviewed for QAPI in the sample of 40. Findings Include: R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family Member & Power of Attorney/POA) and V22 (Family Member). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control professional standards when completing wound care for one (R45) of seven residents reviewed for infection control out of a sample of 40.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure preventative cleaning measures were implemented to promote pest control and maintain an environment free of insects. This failure has the ability to affect all 62 residents living at the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure a resident was free from resident to resident abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately label insulin with resident's name and date of opening for 6 (R3, R7, R11, R14, R16, R37) of 12 residents reviewed for medication labeling and storage in a sample of 26.