El Dorado Care: DNR Order Confusion Leaves Family - KS
The guardian for Resident 8 contacted El Dorado Care and Rehab multiple times about the DNR confusion. During an April 9 inspection, the guardian told investigators at 11:22 AM that the resident "used to be a DNR" but "the state did an audit last year and he had to be full code." The guardian said he couldn't understand why this happened and had repeatedly asked the facility for assistance.
Nobody had clear answers.
Licensed Nurse J told inspectors at 2:45 PM that she "could not recall why R8's DNR was discontinued." The discontinuation had happened months earlier, yet the nurse responsible for the resident's care had no memory of such a significant change to his medical orders.
Social Service Designee X provided more details but expressed her own confusion about the decision. She revealed that regional staff had completed a "mock survey" and told facility staff that the resident's DNR "was not good as it was signed after the guardianship paperwork was in effect." The Director of Nursing at the time then had the resident's provider discontinue the DNR order.
"She was a bit confused when that occurred," Social Service Designee X told inspectors about her reaction to the DNR discontinuation.
Despite the guardian's repeated requests for help, Social Service Designee X admitted she had not spoken to the guardian about getting assistance to complete a new DNR if desired.
The confusion deepened when three administrative staff members reviewed the resident's electronic medical record during the inspection. Administrative Staff A, Administrative Nurse D, and Administrative Nurse E all reported "they had no knowledge of the concern that the guardian had about the DNR."
This was particularly striking given that the guardian had been asking for help for months. The administrative team's lack of awareness suggested a breakdown in communication about a family's urgent medical decision concerns.
Administrative Nurse D added another layer of confusion, reporting that the resident's guardian had wanted the resident to be "full code" when she had previously spoken to the guardian about hospice care. This contradicted the guardian's clear statement to inspectors that he wanted help understanding why the DNR was discontinued.
The facility's own policy, dated May 2025, states that advance directives "would be respected in accordance with state and federal law and facility policy." The policy requires staff to inquire about advance directives prior to or upon admission and mandates that information about advance directives "shall be displayed prominently in the medical record."
Yet when the guardian sought help understanding changes to his family member's advance directive, multiple staff members either couldn't remember what happened or weren't aware of his concerns.
Administrative Staff A finally took action during the inspection, directing Administrative Nurse E to contact the guardian "to see what they wanted to do with R8's code status." This was the first documented attempt to address the guardian's months-long requests for assistance.
The case reveals how a routine mock survey triggered a chain of events that left a family confused about their loved one's end-of-life care preferences. The resident went from having a DNR order to being designated "full code" for life-sustaining measures, but staff couldn't adequately explain why this dramatic change occurred.
Federal inspectors found the facility failed to ensure the resident's rights were protected regarding advance directives. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
The guardian's persistent questions about the DNR discontinuation remained unanswered even as inspectors documented the communication failures. His family member's code status hung in limbo while staff scrambled to figure out what the guardian actually wanted after months of asking for help they never received.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for El Dorado Care and Rehab from 2026-04-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
EL DORADO CARE AND REHAB in EL DORADO, KS was cited for violations during a health inspection on April 9, 2026.
The guardian for Resident 8 contacted El Dorado Care and Rehab multiple times about the DNR confusion.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at EL DORADO CARE AND REHAB?
- The guardian for Resident 8 contacted El Dorado Care and Rehab multiple times about the DNR confusion.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in EL DORADO, KS, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from EL DORADO CARE AND REHAB or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 175324.
- Has this facility had violations before?
- To check EL DORADO CARE AND REHAB's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.