The Springs of El Dorado

Inspectors wroteBased on observations, interview, record review, and facility policy review, it was determined the facility failed to ensure provider orders were completed for one resident (Resident #2) of three residents reviewed for wound care.

Inspectors wroteBased on record review, interview, and facility document review, the facility failed to provide a safe care environment by placing one (Resident #1) of five residents reviewed for Quality of Care, at risk. Specifically, Resident #1 consumed alcohol brought in by Certified Nursing Assistant (CNA) #3 and became intoxicated in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to notify the resident, and/or the resident's representative, in writing and provide written information regarding the facility's bed-hold policy when a resident was transferred to the hospital for three (Residents #40, #61, and #45) of four sampled residents, reviewed for hospitalization. 1. Review of Resident #40's Medicare-5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/2025, revealed a Brief Interview for Mental Status (BIMS) score of 10 (indicated the resident had moderate cognitive impairment). Resident #40 ' s MDS also revealed the resident had active medical diagnoses which included: diabetes mellitus, non-Alzheimer ' s dementia, and respiratory failure. a. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure food items in the refrigerator, freezer and storage room were covered or sealed; one (1) of one (1) ice machine was maintained in clean and sanitary condition; dietary staff washed their hands before handling food or clean equipment; ceiling tiles, air vents, dish washer wall, kitchen door frames were free of, debris, dirt, rust, stains; baseboards were secured for one (1) of two (2) meals observed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure dented cans were discarded to prevent bacteria growth; food items had opened and/or received dates; shelves were clean of debris; and contaminated pan covers were not placed on food to be served. These practices had the potential to affect 80 (total census 81) residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure that resident laundry was transported in a way to prevent the spread of infection. This failed practice had the potential to affect 81 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure physicians orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for 1 (Residents #45) of 5 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the refrigerated narcotic medications were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property.

Inspectors wroteBased on observation, record review and interview, the facility failed ensure fingernails were cleaned, trimmed, smooth and free of jagged edges to promote good personal hygiene and grooming for 1 (Resident #15) of 1 sampled resident who was dependent for nail care.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure parameters were put in place to ensure the correct dosage of oxygen was administered to enable the Physician to determine the dosage needed for 1 (Resident #27) sampled resident.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents on the secured unit were supervised while smoking to decrease the potential for injury for 2 (Residents #37 and #71) of 2 sampled residents who were smoking without supervision.

Inspectors wroteBased on record review and interview, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 (Resident #52) of 1 sampled resident who fell during transport in the facility van. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #52 who fell out of the wheelchair in the facility van during transport on 11/22/22. The failed practice had the potential to affect all 63 residents who resided in the facility as documented on the Daily Census Report provided by the Administrator on 12/27/22 at 10:27 a.m. The Administrator was notified of the Immediate Jeopardy on 12/27/22 at 3:50 PM.

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary staff washed their hands between clean and dirty tasks, foods were utilized prior to their use by dates, containers were sealed to prevent the potential for food borne illness for residents who received meals from 1 of 1 kitchen and the kitchen and equipment was cleaned to prevent cross contamination. These failed practices had the potential to affect 62 residents (Total Census: 63) who obtained their meals from 1 of 1 kitchen according to a list provided by the Administrator on 12/29/22 at 1:18 PM.

Inspectors wroteBased on record review and interview, the facility failed to notify residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of a single confirmed infection of COVID-19 for 4 (Residents #1, #3, #36 and #52) sampled residents whose records were reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a label was placed on the formula bottle to identify the type of formula the resident was receiving for 1 (Resident #6) of 3 (Residents #6, #26 and #171) sampled residents who received continuous enteral feedings according to the list provided by the Administrator on 12/30/2022 at 10:24 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to administer oxygen at the correct flow rate for 1 (Resident #171) of 3 (Residents #6, #171 and #221) sampled residents who had physician orders for oxygen. This failed practice had the potential to affect 6 residents who had a physician's order for oxygen according to a list provided by the Administrator on 12/30/2022 at 10:24 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the written menu was followed to ensure the nutritional needs of the residents were met. The failed practice had the ability to effect 3 sampled residents who had physician orders for a pureed diet as documented on a list provided by the Administrator on 12/29/22 at 1:20 PM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a water pitcher was provided to ensure water was assessable at the bedside to prevent the potential for dehydration for 1 (Resident #170) of 3 (Residents #61, #170 and #171) sampled residents who were recently admitted to the facility according to the list provided by the Business Office Manager on 12/30/2022 at 10:34 AM, and 1 (Resident #170) of 1 sampled resident who had a Urinary Tract Infection (UTI) on admission according to the list provided by the Director of Nursing (DON) on 12/30/2022 at 11:10 AM.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate to facilitate the ability to plan and provide necessary care and services for 1 (Resident #3) of 14 (Residents #1, #3, #6, #24, #26, #27, #29, #33, #49, #52, #55, #61, #67 and #171) sampled residents whose MDS were reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the baseline care plan was completed within 48 hours of admission for 1 (Resident #61) of 1 sampled resident whose baseline care plan was reviewed. The failed practice had the potential to affect all 63 residents who resided in the facility according to the Census and Conditions of Residents provided by the Administrator on 12/27/22 at 1:00 PM.

Inspectors wroteBased on record review and interview, the facility failed to complete a comprehensive care plan within 21 days of admission for 1 (Resident #61) of 1 sampled resident whose care plans was reviewed. The failed practice had the potential to affect all 63 residents who resided in the facility according to the Census and Conditions of Residents provided by the Administrator on 12/27/22 at 1:00 PM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the care plan to include oxygen and a recent diagnosis of Pneumonia for 1 (Resident #171) of 3 (Residents #6, #171 and #221) sampled residents who received oxygen. This failed practice had the potential to affect 6 residents in the facility who had physician orders for oxygen according to a list provided by the Administrator on 12/30/22 at 10:24 AM.