Inspection Reports for El Dorado Operator LLC

An offsite revisit survey was conducted on 11/27/2018 for all previous deficiencies cited on 09/27/2018.

All deficiencies have been corrected as of the compliance date of 10/27/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found a most serious deficiency at an "E" level, pattern, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-10-27.

The inspection was a Health Resurvey conducted to evaluate the facility's compliance with regulations following prior deficiencies.

The facility was found deficient in multiple areas including failure to report alleged violations timely, incomplete investigations of alleged theft, failure to develop and implement baseline and comprehensive care plans timely, failure to revise care plans after incidents, and failure to ensure resident safety resulting in an elopement incident and delayed fall interventions.

The plan of correction addresses deficiencies identified in a prior inspection related to a report of missing money from resident #24 and care plan reviews for residents #4, #7, #8, and #39.

The report details corrective actions including re-education of staff on reporting abuse and neglect, resident safety regarding valuables, and care plan review and updates for multiple residents. The facility implemented monitoring and re-education plans to ensure compliance and resident safety.

This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

All previously cited deficiencies were corrected as of the revisit date, with each deficiency fully identified by regulation number and marked as completed.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective April 5, 2017.

The inspection was a health resurvey to assess compliance with regulatory requirements related to resident grievances, housekeeping, maintenance, care planning, medication administration, infection control, and environmental safety.

The facility failed to act on resident council grievances regarding housekeeping and supplies, maintain sanitary and comfortable living conditions, develop comprehensive care plans for urinary catheter care, provide necessary restorative services, monitor medications with black box warnings, ensure proper medication administration, maintain sanitary food service and storage, and uphold infection control and environmental safety standards.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection on 03/08/2017. It outlines corrective actions taken and planned to address cited deficiencies and ensure compliance with regulatory requirements.

The plan details multiple deficiencies related to housekeeping, environmental cleanliness, catheter care, medication administration, restorative programming, dietary sanitation, and medication storage. The facility has implemented corrective actions including staff re-education, environmental cleaning, equipment repair, audits, and ongoing monitoring to prevent recurrence and ensure resident safety and quality of care.

This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.

The report confirms that all previously cited deficiencies identified by regulation numbers 483.24 and 483.25(k)(l) have been corrected as of the revisit date.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be a "D" level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective February 20, 2017.

This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.

The facility recognized deficiencies related to resident care including assessment and documentation of change of condition, oral hygiene and denture care, bathing preferences and hygiene care. The Plan of Correction outlines re-education of staff, monitoring, and ongoing quality assurance interventions to address these issues.

This Plan of Correction is in response to deficiencies cited following a complaint investigation (El Dorado complaint 01242017).

Complaint investigation #109884 was conducted to assess the facility's compliance with care and services provided to residents, focusing on pain management, dialysis, and quality of life.

The facility failed to ensure adequate nursing assessments during periods of illness for three residents, failed to monitor and document acute illnesses properly, and did not provide bathing and personal hygiene services as expected for two residents. There were issues with documentation, follow-up with physicians, and resident care, including neglect of oral care and hygiene.

The visit was triggered by complaint investigation #109884, which found deficiencies related to inadequate nursing assessments during illness, failure to monitor and document acute illnesses, and failure to provide adequate bathing and personal hygiene services.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report confirms that the deficiencies previously cited have been corrected as of the revisit date.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be F323, a 'D' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective November 20, 2016.

The inspection was conducted as a complaint investigation based on complaint investigations #107564, #106315, and #107512.

The facility failed to ensure adequate supervision to prevent accidents, as evidenced by a resident with severe cognitive impairment who left the facility unobserved in a wheelchair and traveled approximately 1/4 mile away without staff knowledge. The resident was found safe with no injury, but the incident revealed a deficiency in supervision and elopement risk management.

The findings represent the results of complaint investigations #107564, #106315, and #107512. The resident left the facility without staff knowledge, indicating a failure in supervision and accident hazard prevention.

The document is a Plan of Correction submitted in response to a complaint investigation related to an incident involving Resident #01 leaving the premises without notifying facility staff on 10/29/2016.

The facility acknowledged a deficiency related to resident safety and implemented corrective actions including counseling the resident, establishing outdoor privileges based on BIMS scores, and initiating monitoring programs to ensure compliance and resident safety.

Complaint investigation related to an incident on 10/29/2016 involving Resident #01 leaving the facility without notifying staff. The deficiency was substantiated and corrective actions were implemented.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. A plan of correction was required, and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The revisit confirmed that the deficiencies previously cited under regulations 483.20(k)(3)(i) and 483.60(b),(d),(e) were corrected as of the revisit date.

An Abbreviated Survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be 'E' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The inspection was conducted as a complaint investigation (#102403) regarding medication administration and storage practices at the facility.

The facility failed to follow professional standards in medication preparation and administration by licensed nursing staff, and failed to maintain medications, including narcotics, in locked compartments as required by policy and law.

The complaint investigation (#102403) substantiated that medication administration and storage practices did not meet professional standards and regulatory requirements.

The document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey conducted on or before 07/12/2016.

Deficiencies involved medication administration and securement, with potential to affect all residents. The facility implemented staff in-service training and ongoing medication pass observations to ensure compliance with policies and regulations.

This Plan of Correction is linked to a complaint investigation identified as GLC El Dorado complaint dated 07/13/2016.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report confirms that the deficiencies previously cited, including one identified by regulation 483.25(h), were corrected as of 03/10/2016.

This document is a Plan of Correction submitted by the facility in response to cited deficiencies from a prior inspection, outlining corrective actions to address the issues.

The facility acknowledged deficiencies related to resident care, specifically involving resident #1, and described multiple corrective actions including reassessment, care plan updates, staff in-services, and implementation of a 'Stop and Watch' program to monitor resident condition changes.

An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency to be at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the facility's history of noncompliance on a prior resurvey, no opportunity to correct deficiencies before remedies are imposed was given.

This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The revisit confirmed that the previously cited deficiency with ID Prefix F0314 related to regulation 483.25(c) was corrected as of 12/08/2015. No other deficiencies or uncorrected issues were noted.

This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions have been completed.

The report confirms that the previously cited deficiency with regulation number 28-39-158(a) has been corrected as of 12/08/2015. No other deficiencies or uncorrected issues are noted.

This post-certification revisit was conducted to verify that previously cited deficiencies from the prior survey on 2015-08-27 were corrected.

The revisit confirmed that all previously identified deficiencies were corrected as of 2015-11-04, with no uncorrected deficiencies remaining.

This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.

The report confirms that the deficiency identified by regulation number 28-39-160 with ID prefix S0770 was corrected as of 11/04/2015.

The revisit was conducted on November 4, 2015, as a result of the August 27, 2015 Health survey to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.

The revisit found the most serious deficiency in the facility to be a 'G' level deficiency related to noncompliance with F314, Pressure Ulcers. Due to this noncompliance, a denial of payment for new Medicare and Medicaid admissions was imposed effective November 27, 2015, and termination of the provider agreement was recommended.

This document is a Plan of Correction submitted by Golden Living El Dorado in response to deficiencies cited during a prior survey conducted on 8/27/2015.

The Plan of Correction addresses deficiencies related to resident care, including wound care and dietary management. Corrective actions include staff in-service training, implementation of care audits, monitoring by the Director of Nursing Services, and dietary oversight by a Licensed Registered Dietician and a promoted dietary manager in training.

The inspection was conducted as a non-compliance revisit and complaint investigation #93426 regarding the facility's failure to prevent and properly treat pressure sores in a resident.

The facility failed to develop and implement timely interventions to prevent the development and promote healing of pressure ulcers for one resident (#77). The resident developed an unstageable pressure ulcer on the spine and two stage II pressure ulcers on the buttocks. Documentation and interviews revealed inadequate repositioning, delayed notification to the physician, and insufficient preventive measures.

The visit was a complaint investigation (#93426) and non-compliance revisit focused on pressure sore prevention and treatment. The complaint was substantiated by findings of inadequate care leading to pressure ulcers.

This document is a Plan of Correction submitted by Golden Living El Dorado facility in response to deficiencies cited in a prior inspection report, outlining corrective actions to address identified issues.

The facility acknowledges multiple deficiencies affecting residents and facility conditions, including medication administration errors, skin care issues, weight monitoring delays, environmental maintenance, and dietary service concerns. Corrective actions include staff in-service training, enhanced monitoring, repairs, cleaning, and policy development to ensure compliance and resident quality of care.

A health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency in the facility to be at a 'G' level, resulting in a denial of payment for new Medicare and Medicaid admissions effective November 27, 2015, until substantial compliance is achieved or the provider agreement is terminated.

The inspection was conducted as a Health Resurvey and Complaint Investigation related to allegations and compliance with regulatory requirements.

The facility was found deficient in multiple areas including failure to notify physicians of significant changes in residents' conditions, inadequate housekeeping and maintenance services, failure to develop comprehensive and individualized care plans especially related to skin conditions and bruising, failure to ensure use of prescribed splints for range of motion, failure to prevent significant weight loss in a resident, medication errors related to administration of Lasix despite low blood pressure, and unsanitary food storage and preparation conditions.

The visit was triggered by complaints related to medication errors, failure to notify physicians of significant changes, inadequate housekeeping, and care planning deficiencies.

This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit confirmed that the deficiency identified under regulation 483.15(h)(3) with ID prefix F0254 was corrected as of 08/20/2015.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be an 'E' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.

This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Golden Living El Dorado.

The facility acknowledged a deficiency related to laundry services that had the potential to affect all residents. The Plan of Correction outlines steps to ensure adequate staffing, linen availability, and ongoing monitoring to maintain compliance.

The Plan of Correction addresses deficiencies cited during a complaint investigation at Golden Living El Dorado.

The inspection was conducted as a complaint investigation based on complaint investigations #89421 and #88905 regarding the facility's laundry and linen services.

The facility failed to provide adequate clean bed and bath linens as well as personal clothing laundry services for 40 residents. Observations included soiled laundry barrels, lack of laundry staff, insufficient linens in closets, and difficulty in providing linens and personal clothing during residents' bath days.

The visit was triggered by complaint investigations #89421 and #88905. The facility was found to have inadequate laundry services, including lack of linens and personal clothing for residents, and issues with contracted laundry/housekeeping services.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended.

This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report shows that all previously cited deficiencies were corrected by the revisit date of 06/26/2014, with no uncorrected deficiencies remaining.

This revisit inspection was conducted to verify that previously reported deficiencies had been corrected by the facility.

The report confirms that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 06/26/2014.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, as required by State and Federal Law within ten days of the survey.

The facility acknowledges multiple deficiencies that have the potential to affect residents, including issues related to bathing preferences, equipment malfunctions, environmental repairs, staffing shortages, dietary service concerns, and infection control. The Plan of Correction outlines specific corrective actions, staff in-service training, equipment replacement, and ongoing monitoring to achieve substantial compliance by 6/26/2014.

The inspection was conducted as a health resurvey and complaint investigation related to multiple resident care and facility concerns.

The facility was found deficient in multiple areas including failure to provide resident choice in bathing due to a non-functioning whirlpool tub, failure to accommodate resident preferences for shower sling causing discomfort and pressure ulcers, inadequate activities for residents, poor housekeeping and maintenance, failure to prevent pressure ulcers, improper catheter care leading to infection risk, inadequate restorative services, insufficient nursing staff to meet resident needs, unsanitary food storage and preparation, malfunctioning whirlpool tub, and unsafe and unsanitary environment conditions.

The inspection included a complaint investigation #70865 regarding resident care issues including bathing preferences, pressure ulcers, catheter care, staffing, and environmental concerns.

This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report shows that all previously cited deficiencies were corrected by the revisit date of 08/09/2013, with no uncorrected deficiencies remaining.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, as mandated by State and Federal Law within ten days of the survey.

The facility acknowledges multiple deficiencies affecting residents and staff, including issues with resident funds handling, physical environment repairs, medication administration, food storage, disinfection protocols, and plumbing maintenance. Corrective actions and audits have been planned or implemented to achieve substantial compliance by 08/09/2013.

The inspection was conducted as a Health Resurvey and complaint investigation #63362 to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including improper management of resident personal funds, inadequate housekeeping and maintenance services, failure to monitor unnecessary drug use, medication errors exceeding 5%, unsanitary food storage and preparation conditions, inadequate infection control practices, and unsafe and unsanitary kitchen environment.

The inspection included a complaint investigation identified as #63362.

This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit confirmed that all previously cited deficiencies identified by regulation numbers 483.10(c)(6), 483.10(c)(7), 483.12(b)(1)&(2), 483.35(i), and 483.65 were corrected as of 04/30/2012.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior survey report to demonstrate corrective actions and compliance with regulatory requirements.

The Plan of Correction outlines specific corrective actions taken or planned for various deficiencies including resident account management, surety bond increase, bed hold policy tracking, food delivery procedures, kitchen cleanliness, and infection control practices. The facility commits to ongoing monitoring and re-education to maintain substantial compliance.

The inspection was conducted as a health facility resurvey and complaint investigation #55029 to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including failure to convey deceased residents' personal funds within 30 days, failure to maintain a surety bond covering resident personal funds, failure to provide bed-hold policy notices upon resident transfer to acute care, unsanitary food storage and preparation conditions, and inadequate infection control practices during dressing changes.

The visit included a complaint investigation #55029. The complaint involved issues such as failure to convey deceased residents' funds, lack of surety bond coverage, failure to provide bed hold notices, unsanitary food handling, and infection control breaches.