El Dorado Care and Rehab

In the surveyor’s words

From the most serious findings on record at El Dorado Care and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 10, 2021

  The facility reported a census of 35 residents, with 5 identified at risk for elopement and 3 reviewed for elopement. Based on record review and interviews, the facility failed to provide adequate supervision and assistive devices to prevent Resident (R) 1 from leaving the facility without staff knowledge. R1 removed a screw from his window, removed the screen, crawled out of the window, and left the facility. He walked to a grocery store on a highway 1 and ,[DATE] miles from the facility at night. The city police picked him up and could not determine where he belonged. They transported him to a homeless shelter. He had an expired identification which led the police to call a family member. […]

• Actual harm, isolatedF692Apr 9, 2026

  Based on observation, interview, and record review, the facility failed to provide a vegetarian diet to meet the resident's nutritional needs and failed to initiate weight loss interventions for R31, to prevent a significant weight loss of 16.30 percent (%) in 19 days. Additionally, the facility failed to provide R2 with a breakfast meal on scheduled dialysis (procedure where impurities or wastes were removed from the blood) treatment days, to meet R2's nutritional needs. Findings included:- R31's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). […]

• No harm, potential for more than minimal, widespreadF851Apr 9, 2026

  Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year (FY) 2026 Quarter 1 and FY 2025 Quarter 3 had excessively low weekend staff.On 04/08/26 at 10:44 AM, Administrative Staff A stated she was aware there was a problem and found that the previous Business Office Manager (BOM) had submitted the information incorrectly. […]

• No harm, potential for more than minimal, widespreadF880Apr 9, 2026

  Based on interviews, observation, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing wound care to a Resident (R) 2 with a Foley catheter (tube inserted into the bladder to drain urine into a collection bag), colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body), and a hemodialysis port (a subcutaneous vascular access device placed under the skin to provide long-term access for hemodialysis {procedure where impurities or wastes were removed from the blood}). […]

• No harm, potential for more than minimal, widespreadF880Apr 15, 2021

  The facility reported a census of 29 residents. Based on observation, interview and record review, the facility failed to properly screen visitors upon entering the facility related to COVID screenings for visitors. Findings Included: - Record Review on 04/14/21 at 07:57 AM revealed incomplete logs for indoor visitor screenings. The following concerns included: 1.) Fourteen visitors lacked temperature recorded in the screening logs. 2.) Twenty-Eight visitors lacked Pass screen recorded in the screening logs. 3.) Eighteen visitors lacked Mask recorded in the screening logs. 4.) Twenty-Eight visitors lacked having the Time in recorded in the screening logs. 5.) Fifty-One visitors lacked the Time out recorded in the screening logs. […]