Eldorado Rehab & Healthcare

In the surveyor’s words

From the most serious findings on record at Eldorado Rehab & Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 16, 2024

  Based on observation, interview and record review, the facility failed to protect a resident's right to be free from neglect when they failed to: 1. appropriately assess a resident at risk for wandering, 2. ensure wandering and elopement behavior attempts were immediately reported to nursing staff, 3. ensure residents who elope were provided care and services in a manner to confirm safety, 4. immediately and thoroughly investigate an incident of elopement, 5. revise and individualize a resident's plan of care to prevent further attempts of elopement, and 6. conduct a physical assessment to ensure wellbeing immediately following an elopement for 1 (R59) of 2 residents reviewed for abuse in the sample of 40. […]

• Immediate jeopardy, isolatedF689Feb 16, 2024

  Based 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. […]

• Actual harm, isolatedF803Sep 13, 2022

  Based on interview, record review, and observation, the facility failed to provide a Dental Soft/Mechanical Soft diet to 2 of 4 residents (R2, R3) reviewed for mechanically altered diets in the sample of 4. This failure resulted in the wrong textured diet being provided to R2 which resulted in a choking incident and a trip to the emergency room . Findings include: 1.) R2's Face Sheet dated [DATE], documents R2 had diagnoses that included Dementia without Behavior Disturbance, Dysphagia, History of Transient Ishecmic Attacks, History of Cerebral Infarction and [CONDITION(S)], Hypertension and [CONDITION(S)]. […]

• No harm, potential for more than minimal, widespreadF584Feb 16, 2024

  Based 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. Findings include: On 02/06/24 at 12:14 PM, Dining room observed having brown ceiling tiles around ceiling vent area. On 02/08/24 at approximately 9:59 A.M., V4 (Maintenance Supervisor) and V11 (Regional Maintenance) were asked about the vent in the dining room with discolored tiles around it. V4 stated that he was aware of the discoloration of the ceiling tiles around the vent. V4 stated that it was on his list to do he has just been busy and it hasn't been that way long. […]

• No harm, potential for more than minimal, widespreadF812Feb 16, 2024

  Based 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. […]