El Dorado Care And Rehab

had a fall. [DATE] at 11:22 AM, R8's Guardian reported that R8 used to be a DNR and reported the

she could not recall why R8's DNR was discontinued in [DATE]. On [DATE] at 02:50 PM, Social

[DATE]. SSD X reported she was told R8's DNR was not good as it was signed after the guardianship paperwork was in effect. SSD X reported that the Director of Nursing at the time had R8's provider discontinue the DNR and reported she was a bit confused when that occurred. SSD X reported she had not spoken to R8's guardian about a request to have assistance to have a DNR completed. On [DATE] at 03:02 PM, Administrative Staff A, Administrative Nurse D, and Administrative Nurse E reviewed R8's EMR of the DNR, progress notes, orders, and guardian ship paperwork, and they all reported that they had no knowledge of the concern that the guardian had about the DNR.

Administrative Nurse D reported that R8's Guardian wanted R8 to be a full code when she had spoken to guardian about hospice.

Administrative Staff A reported that R8's paperwork for the DNR was accurate and directed Administrative Nurse E to contact the Guardian to see what they wanted to do with R8's code status.

The facility's policy Advance Directives, dated 05/2025, documented advance directives would be respected in accordance with state and federal law and facility policy.

Prior to or upon admission of a resident, the Social Services Director or designee would inquire about the resident, and/or his/her family members, about the existence of any written advance directives.

Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record.

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

Findings included:- R8's Electronic Medical Record (EMR) revealed diagnoses of chronic respiratory failure (CRF is a long-term, ongoing condition where the respiratory system fails to properly exchange oxygen and carbon dioxide, resulting in persistently low oxygen), and schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R8's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) could not be completed as the resident was rarely/never understood.

Staff assessment revealed R8 had severely impaired cognition.

R8 had no behaviors and required total assistance for all activities of daily living. R8's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 04/28/25 documented R8 was nonverbal, rarely communicated, and was dependent on all cares. R8's Quarterly MDS dated [DATE] documented the resident had no change in mental status, behaviors, or assistance required with activities of daily living R8's Care Plan, dated 04/26/23, revealed staff were instructed to inspect the resident's skin weekly and as needed.

Staff would observe R8 for redness, open areas, scratches, cuts, bruises, and report any changes to the nurse. R8's Weekly Skin Note, reviewed from 03/28/26 and 04/02/26, revealed no documentation for an abrasion or bruise to R8's forehead.

During an initial observation (on the first day of the facility's annual resurvey) on 04/06/26 at 09:15 AM, R8 laid in his bed with the head of his bed elevated.

The resident had a red abrasion, which measured approximately 0.5 cm by 2 centimeters (cm) present on the right side of his forehead. R8 shook his head side to side in a motion indicating no, when asked if he had a fall. R8's progress notes lacked evidence that staff identified the abrasion to R8's forehead and/or investigated the origin of the injury until the next day on 04/07/26. R8's Progress Note, dated 04/07/26, at 05:10 PM documented R8 had a purple abrasion to the right side of his forehead.

The area was closed and measured 0.3 cm by 2.5 cm by 0 cm. R8 was unable to describe how the injury occurred.

Staff were questioned about the origin of the resident's injury, and no event was noted to occur.

The note indicated R8's head may have hit the wall during cares. R8 recently had a room change, and his bed was placed against the wall. A fall mat was placed to the left side of the resident's bed to prevent him from grazing his head on the wall.

During an interview on 04/07/26 at 09:54 AM Certified Nurse Aide (CNA) O reported she had not noticed the abrasion/redness on R8's forehead.

During an interview on 04/07/26 at 02:29 PM, Licensed Nurse (LN) J reported that she was told by the night nurse on 04/06/26 that R8 had an abrasion on his forehead and she was not sure how it happened. LN J reported that she did not document the area on R8's forehead as she thought the night nurse did.

During an interview on 04/07/26 at 03:33 PM, CNA O reported that any new skin issue identified on a resident would be reported to the nurse.

The staff were required to write a statement for an injury such as a bruise, or skin tear.

During an interview on 04/07/26 at 05:01 PM, Administrative Nurse E stated she was not aware that R8 had an abrasion on his forehead and reported that the nurse should have reported, assessed, and completed a risk management for the abrasion.

Administrative Nurse E further stated a root cause analysis should have been completed to assess how R8 would have received an abrasion.

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

Findings included: - R5's Electronic Medical Record (EMR) recorded diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), chronic kidney disease Stage 3 (moderate to severe loss of kidney function), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). R5's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition.

The MDS recorded R5 required staff assistance with most activities of daily living (ADLs).

The MDS recorded R5 received dialysis (a procedure where impurities or wastes are removed from the blood), and oxygen therapy.

The Activities of Daily Living (ADLs) Care Area Assessment (CAA), dated 07/01/25, recorded R5 required substantial assistance with ADLs requiring the lower body, he is unable to ambulate and had poor balance. R5 would operate his wheelchair with set-up assistance and was a fall risk.

The ADL Care Plan, dated 12/16/25, recorded staff would assist R5 with ADLs and ambulation as needed.

The care plan documented that staff would monitor and report changes in mental status, lethargy, tiredness, fatigue, tremors, seizures and breathing difficulties.

The care plan documented R5 had renal insufficiency due to chronic kidney disease and staff would monitor lab results, electrolytes, and report to the physician results.

The Nurse's Note, dated 12/09/25 at 01:13 PM, documented the lab called the facility and stated the resident had a critical lab hemoglobin (Hgb-measure of blood that carried oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs) of 6.1 (normal 13.5 to 17.5 grams per deciliter (g/dl) for men).

The Nurse's Note, dated 12/09/25 02:15 PM, documented the facility received a call from the provider to send R5 to the emergency room due to the critical lab values.

The 12/09/25 at 02:40 PM, Nurse's Note documented R5 left the facility via stretcher per ambulance.

The 12/16/25 at 06:06 PM, documented R5 returned to the facility from the hospital for end stage renal disease and anemia. R5 had a dialysis port on the left upper chest. R5's clinical lacked evidence of the bed hold policy and the facility was unable to provide evidence upon request.

The facility was unable to provide evidence that the facility notified the LTCO of the resident's transfer/discharge from the facility. On 04/08/26 at 09:30 AM, Social Service X verified the facility lacked a bed hold notice when R5 was discharged to the hospital and verified the Ombudsman was not notified of the resident's discharge to the hospital.

The facility's Bed Hold policy, dated May 2026, documented the facility staff shall inform residents upon admission and prior to a transfer for hospitalization (unless for an emergency) or therapeutic leave of the bed-hold policy.

The policy documented upon admission and when a resident is transferred for a non-emergency hospitalization or for therapeutic leave, a representative of the business office would provide information concerning the bed hold.

When emergency transfers are necessary, the facility would provide the resident and the resident representative with information concerning the bed-hold policy per state law as applicable. A copy of the resident's bed hold policy would be filed in the resident's medical record.

Upon request the facility failed to provide an Ombudsman Notification policy

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

expected to offer and complete facial hair removal/shaving, and nails were to be cleaned on shower

to file, clean, and trim fingernails for the residents on their bath day and as needed.

The nurse would cut the resident's fingernails that were diabetic.

Administrative Nurse F expected the CNAs to remove facial hair on shower days and as needed.

She also reported that facial hair should be removed when requested and per the resident's preferences, which would be documented on the resident's care plan.

The facility policy Quality of Life-Activities of Daily Living, dated 03/26, documented the facility assisted the residents in maintaining and/or achieving independent functioning, dignity, and well-being.

Residents who are unable to carry out activities of daily living received the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene.

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

assistance in placing his hearing aids, which placed the resident at risk for social isolation, mental

revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and malformation of ear causing hearing impairment. R43's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) that could not be completed as the resident was rarely/never understood.

Staff assessment revealed R31 had severely impaired cognition. R43's MDS revealed she wore a hearing aide. R43's Communication Care Area Assessment (CAA), dated 10/17/25, documented R43 relied on staff to have her needs met. R43's Quarterly MDS, dated [DATE], documented no change in the resident's BIMS or hearing aid use. R43's Care Plan, dated 01/03/23, revealed staff would ensure availability and functioning of adaptive communication equipment, which included a message board and a hearing aid to the right ear. R43's Care Plan, with a revised date of 01/29/25, instructed staff to provide her hearing aid for the right ear, which was to be worn during the day and taken off at night.

The case was to be left at the nurses' station and charged overnight. R43's Physician Orders documented the resident could be seen by specialists as needed including audiologist of choice and they were to provide care as needed, dated 01/30/23. R43's Activities Note, dated 08/29/25 at 11:40 AM, documented R8 was hearing impaired and wore a hearing aid in the right ear, when available. R43's Activities Note, dated 09/30/25 at 10:23 AM, documented R8 had limited communication and was hearing impaired. On 04/06/26 at 10:20 AM, R43 sat in her wheelchair with no hearing aid noted. On 04/07/26 at 12:45 PM, R43 sat in the dining room with no hearing aid observed in her right ear. On 04/06/26 at 10:20 AM, Activity Director Z reported that R43 did not have a hearing aid.

The staff had to speak loudly in her right ear so she could hear.

Activity Director Z reported that R43 did not speak often. On 04/07/26 at 09:47 AM, Certified Nurse Aide (CNA) N and Certified Medication Aide (CMA) R reported that R43 did not have a hearing aid, and they had never seen one. On 04/07/26 at 03:17 PM, CNA P and CNA O reported that R43 did not have a hearing aid, and they did not know if she was care planned for the use of a hearing aid. On 04/07/26 at 04:30 PM, Administrative Nurse F reported that R43 required a hearing aid and was care planned for the use of a hearing aid to the right ear.

Administrative Nurse F reported she was not sure if R43 had a hearing aid. On 04/07/26 at 04:36 PM, Activity Director Z reported that R43 had not used a hearing aid since they quit working some time last year.

She reported the resident's hearing aid would not hold a charge.

Activity Director Z stated she had informed a nurse about the residents' hearing aid. On 04/07/26 at 04:50 PM, Social Service Designee (SSD) X reported R43's hearing aid broke four or five months ago. SSD X tried to contact R43's durable power of attorney and was unable to get ahold of him about the hearing aid.

She was not sure if the hearing aid would be covered or if R43 had personal funds to cover the hearing aid repair and reported that this was documented in R43s EMR. SSD X reported she did not think that R43 ever had an appointment with an audiologist. On 04/08/26 at 11:00 AM, Activity Director Z reported R43 had a hearing aid that charged at that nurse's desk.

Activity Director Z then applied the hearing aid into R43's right ear and R43 smiled. On 04/08/26 at 01:54 PM, Administrative Nurse D stated that she expected staff to make sure resident hearing aids were offered and placed on the residents as ordered.

Administrative Nurse D reported that an unnamed facility nurse purchased R43 a hearing aid and she was not sure when it arrived but noted that it had been at the nurse's desk charging.

The facility did not provide a policy for hearing aids.

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

had a lot of falls and that she had a fall mat beside the bed, and they made observations of her

R22 had falls in the dining room and that they tried to keep an eye on her because she is impulsive

have been left alone in the dining room, as she is impulsive and falls.

Staff should follow the care plan, and 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.

The facility's Assessing Falls and Their Causes Guidelines policy, dated 10/25, documented staff reviewed the residents' plan of care to assess for any special needs of the resident, the resident's current medications, and conditions.

After the fall, an incident report was completed by the nursing supervisor on duty at the time of the fall, and the Director of Nursing Services would be notified no later than 24 hours after the fall occurred.

The staff will evaluate the chain of events or circumstances of the fall and will determine the cause.

Appropriate interventions would be taken to prevent further falls.

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

02/12/26. R2's Physician Orders documented dialysis treatment Monday, Wednesday, and Friday at

04/08/26, no concerns noted. R2's Progress Note, dated 02/12/26 at 03:46 PM, documented R2 had

dated 02/19/26 at 12:34 PM ,documented R2's current weight was 215.2 pounds on 02/13/2026. R2's current diet order was therapeutic renal diet and R2's meal intakes were good at averaging 76-100 percent.

Per documentation, the resident required set-up or clean-up with eating. R2 completes dialysis three times per week.

Will continue monitor weight trends; reassess as indicated. R2's current intakes are adequate to meet estimated needs. R2's Progress Note, dated 03/18/2026 at 04:35 AM, documented R2 up and ready for dialysis, transported per facility van, accompanied by facility staff. R2's Progress Note, dated 03/23/2026 at 08:23 AM, R2 moved to a different dialysis center and his chair time changed to 05:15 AM which started 3/25/26. R2's Nutrition Amount Eaten documented in tasks on EMR reviewed from 02/13/26 through 04/08/26 revealed for breakfast meal intake documented on 02/13/26, 02/16/26, 02/23/26, and 03/06/26 R2 was not available.

The breakfast meal intake documented on 02/20/26, 02/25/26, 02/27/26, 03/02/26, 03/09/26, 03/10/26, 03/13/26, 03/18/26, 03/20/26, 03/23/26, 03/25/26, 03/27/26, 03/28/26, 03/29/26, 04/01/26, 04/02/26, and 04/08/26 breakfast meal was documented non applicable. On 04/06/26 at 02:45 PM, R2 was seated up in his bed completing a crossword puzzle. He reported that he just returned from dialysis. R2 reported that he leaves very early in the morning to be at the dialysis center by 05:00 AM and stated that he does not eat breakfast before he goes to dialysis, as he is not provided one and he is not provided a snack to eat at the center. On 04/07/26 at 07:56 AM, R2 was in bed looking at a book, he reported he did not think he would get up today and was waiting for his breakfast. On 04/08/26 at 05:42 AM, Certified Nurse Aide (CNA) V reported that R2 did not have breakfast this morning and reported that he would usually refuse the breakfast. CNA V reported that there was not an actual meal prepared for R2 to be offered to be refused on dialysis days though. CNA V said to ask CNA S, as she always worked on R2's hallway. On 04/08/26 at 05:44 AM, Licensed Nurse (LN) K reported that R2 started dialysis in February 2026 and cannot recall that he had been offered a breakfast meal before he left for dialysis when he worked those mornings. On 04/08/26 at 06:12 AM, CNA S reported the kitchen was closed at the time R2 woke up to go to dialysis. CNA S reported we do not have alternatives to give him for a meal.

She reported that she did not offer any snacks, food, or drinks to take with him to dialysis. On 04/08/26 at 09:20 AM, Dietary Staff BB (Certified Dietary Manager) reported R2 refused to have breakfast before dialysis, and she reported that it was not documented in R2's progress notes or R2's care plan.

Dietary Staff BB reported that R2 verbalized to her that was his preference. On 04/09/26 at 09:42 AM, Consultant Staff HH (Registered Dietician) reported that R2 should be offered breakfast in the morning before dialysis and reported it was expected that if R2 refused to have a breakfast meal prior to dialysis, it should be documented in the EMR.

The facility's policy Dialysis, Care for a Resident, dated 03/2026, documented communication between the community, and the dialysis facility shall contain nutritional and fluid management, including resident's compliance with diet, and/or after dialysis.

The facility's policy Frequency of Meals, dated 10/2025, documented that each resident would receive at least three meals daily, at regular times, comparable to normal mealtimes in the community or in accordance with the resident needs, preferences, requests, and plan of care.

The facility will serve at least three meals or their equivalent daily at scheduled times.

There will not be more than a fourteen (14) hour span between the evening meal and breakfast.

The facility will provide alternative nourishing meals and snacks to residents who want to eat outside scheduled meal service or at non-traditional times.

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

Findings included:.- On [DATE] at 08:05 AM, observation of the 100-200 hall medication cart revealed the following:R41's Novolog (long-acting insulin) pen without an open date or the discard date.On [DATE] at 08:15 AM, observation of the treatment cart revealed four expired stock medication bottles which included:ASA (pain and anti-inflammatory medication) 325 milligrams (mg), expired 01/26.Vitamin D (vitamin supplement) 100 tablets, expired 03/26.Calcium (bone building supplement) 600 mg and Vitamin D 5 micrograms (mcg), expired 07/25.Zinc (mineral supplement) 50 mg. 100 tablets, expired 01/26. On [DATE] at 8:10 AM, Certified Medication Aide M verified the stock medication had expired. On [DATE] at 08:20 AM, Licensed Nurse (LN) G verified the undated insulin pen and stated staff were to date the insulin pens when they are opened.

The facility's Medication Storage policy, dated 03/2026, stated the facility would store all drugs and biologicals in a safe, secure, and orderly manner.

The facility staff shall not use discontinued, outdated, or deteriorated drugs or biologicals and shall be returned to the dispensing pharmacy or destroyed per state regulations.

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

Findings included: - R1's Electronic Medical Record (EMR) recorded

depressive disorder (major mood disorder that causes persistent feelings of sadness), and protein calorie malnutrition (a severe form of undernutrition caused by inadequate intake of protein, calories, and essential nutrients, or by high metabolic demand). R1's admission Minimum Data Set (MDS), dated [DATE], recorded R1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition.

The assessment revealed R1 was independent with oral hygiene and personal care.

The assessment revealed that R1 did not have any natural teeth or tooth fragments, no inflamed or bleeding gums, and no broken or loosely fitting full or partial dentures. R1's Dental Care Area Assessment (CAA), dated 03/06/26, recorded R1 had tooth pain on her right side and started an antibiotic for a dental abscess. R1's Nursing admission Evaluation, dated 02/06/26, recorded the resident did not have her own teeth and did not have any broken or loose fitting full or partial dentures.

The evaluation recorded the resident had recent weight loss.

The assessment lacked any additional dental documentation. R1's Care Plan, dated 02/07/26, lacked any reference to R1's broken, decayed teeth, or the dental services to be provided.

The 02/16/26 at 04:01 PM, Nurses' Notes documented R1 reported she had a tooth abscess on her tooth on the right side and reported her mouth was sore and had been hurting.

The 02/16/26 at 05:22 PM, Nurses' Notes documented the nurse practitioner ordered Clindamycin (antibiotic) 300 milligrams(mg), four times a day for seven days.

The 02/21/26 at 10:48 AM, Nurses Notes documented R1 continued with the antibiotics for the tooth abscess and reported decreased pain.

The 02/22/26 at 12:34 AM, Nurses Notes documented the resident continued to receive Clindamycin for the abscessed teeth and denies any adverse effects at this time. On 04/06/26 at 01:30 PM, observation of R1's sitting in the side of the bed with her room tray in front of her and eating a salad.

Observation revealed R1 mouth she had missing teeth, except one that was decayed and split in pieces and one that had broken off at the lower jaw. On 04/08/26 at 01:30 PM, Administrative Nuse E verified she had not visualized R1's mouth or teeth until today and verified R1 was edentulous except for the two broken teeth, and verified the resident was not currently on the facility dental services provided by an outside source.

Administrative Nurse E verified R1 had not had any dental care or services since admission to the facility, and they would investigate having her see a dentist for continued dental care.

The facility's Routine Dental Care policy, dated November 2025, documented that each resident would receive routine dental care.

The policy documented nursing care staff would conduct ongoing health assessments to assure that each resident receives adequate oral hygiene, The attending physician would be notified of a residents' need for dental treatment and order dental consultation as appropriate The facility's routine dental care includes, but is not limited to and initial evaluation of each residents dental needs, consultation with the resident, staff, and the dental consultant, daily dental and oral hygiene plan of care, and preventative care and treatment.

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

Findings included:- On 04/06/26 at 09:00AM, observation revealed R48 sat in a wheelchair in her room with the bedside table in front of her awaiting her breakfast tray.

Continued observation revealed at 09:30 AM a nurse aide came into R48's room and R48 inquired when her breakfast would be delivered.

The nurse aide stated the kitchen had not delivered the food cart to the hall and when they did, she would deliver R48's room tray. On 04/06/26 at 10:00 AM, observation revealed R48 sat in a wheelchair in her room with her bedside table in front of her awaiting breakfast to be delivered to her room On 04/06/26 at 10:05 AM, Administrative Nurse D and Administrative Nurse E were summonsed to R48's room and the surveyor inquired when R48 would and should receive her breakfast and they stated they would check into it and verified the resident should have had her breakfast before 10:00 AM. On 04/06/26 at 10:10 AM R48 received her room tray that consisted of cream of wheat and one piece of toast. R48 stated they did not provide sugar, butter or jelly when they delivered her meal. R48 states she had asked for eggs and orange juice and the staff stated they were out of those items, and this is what they had available. On 04/06/26 at 10:15 AM, Administrative Nurse E verified the kitchen did not print a breakfast ticket for the residents and that is why she did not receive her meal. On 04/08/26 at 11:10 AM, Dietary Staff BB verified R48 had not received her breakfast meal tray because the meal ticket did not print, and staff did not know she had not received her meal and verified the supper meal on 04/05/26 her meal ticket had not printed and that is why she did not receive that supper meal until late.

Dietary Staff BB verified they have corrected the issue, and they will have three check offs to be sure every resident receives their meals and they are served timely.

The facility's Food Preparation and Service policy, dated 10/2025, documented residents are to be provided with food that is palatable, attractive and at a safe and appetizing temperature.

The policy documented that the food service employees should prepare and serve food in a manner that complies with safe food handling practices.

and noodles in-between temperature checks and used the sanitation wipe to wipe off the food. He

the food. On 04/07/26 at 11:37 AM, Dietary Staff EE reported she should have applied her hairnet

a paper towel to clean the thermometer in-between checking the food temperatures.

Dietary Staff CC reported he has always drunk coffee in the kitchen when he works. He reported that he should have covered the plate of food before he placed it in the microwave. On 04/06/26 at 08:30 AM, Dietary Staff BB reported she expected the staff to check the temperatures of the refrigerator, freezer, walk-in cooler, and walk-in freezer and document them on the form three times a day.

Dietary Staff BB expected staff to label, date, and seal all dry, cold, or frozen food and dispose of food when it was outdated, wilted, or moldy.

Dietary Staff BB reported the egg salad should have been disposed by day seven on 04/04/26.

Dietary Staff BB expected staff not to store any food items on the floor and to keep the kitchen areas clean. On 04/07/26 at 01:00 PM, Dietary Staff BB reported she expected the staff to apply a hairnet before they entered the kitchen, then reported she observed Dietary Staff CC use the same paper towel to wipe off the thermometer in-between food temperature checks, and said that was why she laid the wipes on the counter.

She expected the staff to use one wipe after each time the thermometer was used.

Dietary Staff BB reported she expected the staff to never eat or drink in the kitchen and had not seen the staff do that, she expected the staff not to have any personal food, drink or items in the kitchen.

Dietary Staff BB reported she expected the staff to cover the food in the microwave. On 04/08/26 at 11:03 AM, Consultant Staff HH reported completed a monthly kitchen inspection and reported nothing was perfect.

Consultant Staff HH reported he expected the staff to wear a hairnet in the kitchen.

Consultant Staff HH expected the staff to never drink, eat, or have personal items in the kitchen. He expected the staff to check the temperatures of the refrigerator, freezer, walk-in cooler, and walk-in freezer and document them on the form three times a day and expected staff to label, date, store and seal all dry, cold or frozen food and dispose of food when it is outdated, wilted or moldy.

Consultant Staff HH expected the staff to keep the kitchen areas clean and sanitize the thermometer the proper way.

The facility's policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated 10/2025, documented food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.

Hair nets must be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.

Personnel may not eat or drink in the food preparation area.

The facility's policy Sanitation, dated 10/2025, documented all kitchen areas and dining areas shall be kept clean, and free from litter and rubbish.

The facility's policy Food Safety Requirements, dated 10/2025, documented foods shall be received and stored in a manner that complies with safe food handling practices.

Food Services, or other designated staff, will always maintain clean food storage areas.

Food in designated dry storage areas shall be kept off the floor (at least 6 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents (at least 18 inches).

Dry foods that are stored in bins will be removed from original packaging, labeled, and dated.

All foods stored in the refrigerator or freezer will be covered, labeled, and dated.

Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements.

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

and other verifiable and auditable data.

information through the Payroll Based Journal (PBJ) as required.

This deficient practice placed the

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.

She stated she was working with her new BOM to make sure it was being submitted correctly.The facility's Payroll Based Journal F-F851 policy, dated 10/25, documented that the community would submit the payroll data in a uniform format to CMS, including staffing information for community, agency, and contract staff.

The direct care staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long-term care facility.

The data would be submitted electronically based upon specifications determined by CMS, and the reported information would be for direct care staff and would specify whether the individual was an employee of the facility or is engaged by the facility under contract or through an agency.

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El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042

During an interview on 04/07/26 at 10:14 AM, Consultant Staff KK and Consultant Staff JJ reported they should have performed hand hygiene after removing their gloves, and Consultant Staff JJ said she generally would remove both of her gloves.

Consultant Staff KK stated she thought she used a different 4x4 when she cleansed the wound and confirmed she left her gloves on the entire time, touching dressing supplies, the cart, and door handles.

Consultant Staff KK reported she should have removed her gloves after she cleaned the wound and performed hand hygiene.

During an observation on 04/07/26 at 10:10 AM, Consultant Staff II, Consultant Staff JJ, Consultant Staff KK, and another unknown wound care team member were in R2's room (a resident on EBP). R2 was positioned on his right side facing the window as two of the Consultant Staff members assisted him.

Consultant Staff II reported they were almost finished with his wound care.

Observation revealed none of the Consultant Staff in R2's room performing wound care wore a gown as required; they all wore gloves only for the wound care.

During an interview on 04/07/26 at 10:13 AM, Certified Medication Aide (CMA) R reported R2 was on EBP as R2 had a colostomy, urinary catheter, and a dialysis port in his left chest. CMA R reported staff were required to wear a gown and gloves when direct care was provided.

During an interview on 04/07/26 at 10:14 AM, Consultant Staff II reported they should wear the required personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) if a resident was on EBP and confirmed none of the consultant staff had worn a gown when they provided wound care for R2 that morning.

During an interview on 04/07/26 at 10:19 AM, Administrative Nurse E (Infectious Preventionist) stated she expected the wound care staff to use the PPE gowns and gloves for residents that have EBP.

She said she expected the wound care staff and the facility staff to perform hand hygiene when gloves were removed.

Administrative Nurse E reported she expected all wounds to be cleansed by standards of care.

She also expected the staff and wound care staff not to wear soiled gloves to touch clean items or residents.

The facility's policy Enhanced Barrier Precautions, dated 04/2025, documented expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multiple drug-resistant organism (MDRO-common bacteria that have developed resistance to multiple types of antibiotics) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities.

Residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs.

The use of gown and gloves for high-contact resident care activities are indicated.

The facility's policy Handwashing/Hand Hygiene, dated 10/2025, documented the facility considers hand hygiene the primary means to prevent the spread of infections.

Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions:Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice), after removing gloves, and before handling clean or soiled dressings, and gauze pads.

175324 04/09/2026

El Dorado Care and Rehab 900 Country Club Lane El Dorado, KS 67042