El Dorado Care: Fall Prevention Failures - KS
The resident, identified as R22 in inspection records, had documented impulsive behavior and a pattern of resisting care that made her prone to falling. Staff knew she needed close monitoring.
Yet they left her unattended anyway.
On April 8, Licensed Nurse I told inspectors that R22 "had falls in the dining room" and that staff "tried to keep an eye on her because she is impulsive and often resists care." The nurse's own words revealed the contradiction - they knew she needed watching, but the falls kept happening in the same location.
Administrative Nurse F was more direct about the failure. She stated that R22 "should not have been left alone in the dining room, as she is impulsive and falls." The supervisor acknowledged that "staff should follow the care plan" - an admission that they weren't.
The care plan itself had become a source of confusion. Administrative Nurse F admitted she had "inadvertently put on the care plan to remove the sling, as it should not have been a fall intervention, as R22 had Dycem in her wheelchair." Even the supervisor responsible for preventing falls had mistakenly altered the resident's safety interventions.
A certified nursing assistant identified as CNA N told inspectors about the extent of R22's fall risk. The aide said the resident "had a lot of falls and that she had a fall mat beside the bed" and that staff "made observations of her several times a day." The assistant claimed to have "access to the plan of care from the computer to see all her fall interventions."
But having access to a care plan means nothing if staff don't follow it.
The facility's own policy, dated October 2025, outlined clear requirements for fall prevention. Staff were supposed to review each resident's plan of care to assess special needs, current medications, and conditions. After any fall, nursing supervisors had 24 hours to notify the Director of Nursing Services. Staff were required to "evaluate the chain of events or circumstances of the fall" and determine appropriate interventions to prevent future incidents.
The policy existed on paper. The reality was different.
R22's case illustrates a fundamental breakdown in nursing home safety protocols. The resident had documented fall risk factors - impulsivity, care resistance, and a history of multiple daily falls. Her care plan required supervision. Staff knew the dining room was a problem location where she had fallen before.
Despite all these warning signs, they continued leaving her alone in the exact spot where she kept falling.
The inspection found that few residents were affected by the facility's fall prevention failures, and the harm level was classified as minimal. But for R22, the impact was immediate and ongoing. Each fall represented a failure of the system designed to protect her.
Federal inspectors documented the violation under regulations requiring nursing homes to ensure residents receive proper supervision and interventions to prevent accidents. The facility's own policies acknowledged these requirements, making the staff's repeated failures to follow the care plan particularly troubling.
The case reveals how even basic safety measures can break down when staff don't follow established protocols. R22's impulsive behavior made her vulnerable, but the facility's inconsistent supervision made her dangerous situation worse.
Administrative Nurse F's admission that staff should follow the care plan suggests the facility understood its obligations. The question is why those obligations weren't being met, and whether other vulnerable residents were receiving similarly inadequate protection.
The inspection report doesn't indicate whether R22 suffered serious injuries from her repeated falls, or whether the facility has since improved its supervision practices in the dining room where she kept falling.
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: August 5, 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 resident, identified as R22 in inspection records, had documented impulsive behavior and a pattern of resisting care that made her prone to falling.
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.