Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakepoint El Dorado, Llc during CMS and state inspections, most recent first.
The facility failed to provide written notification to residents and their representatives for hospital transfers, affecting residents with complex medical conditions. This deficiency involved multiple residents and was confirmed by staff interviews, revealing a systemic issue with the facility's notification process.
The facility failed to provide six residents with written information about the bed hold policy during hospital transfers, risking their ability to return. Despite complex medical conditions, the policy was only given upon admission, not during subsequent transfers, as confirmed by staff interviews.
A facility's Consultant Pharmacist failed to identify and report medication administration errors for several residents. One resident received blood pressure medication outside prescribed parameters, while another was given an antipsychotic for an unapproved diagnosis. A third resident was administered multiple blood pressure medications outside physician-ordered parameters. The CP's monthly reviews did not document these irregularities, placing residents at risk for unnecessary medication use.
A facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate. A resident with multiple health conditions received blood pressure medications despite their diastolic blood pressure being below the physician-ordered parameters. The CMA acknowledged the error after reviewing the parameters, and the facility lacked a policy for medication errors.
The facility failed to ensure proper storage and monitoring of medications and biologicals, risking ineffective medication for residents. The East medication room had refrigerators with unrecorded temperatures for nine days in December and contained expired yogurts. LN J confirmed the lack of documentation and disposed of the expired items, while Administrative Nurse D stated that night shift staff should record temperatures daily. No policy was provided for medication and biological storage.
The facility failed to develop comprehensive care plans for two residents, one requiring dialysis care and the other with diabetes mellitus. The first resident's care plan lacked focus on dialysis care, despite diagnoses of end-stage renal disease and diabetes. Observations showed non-compliance with fluid restrictions. The second resident's care plan did not address diabetes management, despite a history of severely uncontrolled diabetes and insulin use. The facility's policy required individualized care plans, but these deficiencies placed both residents at risk of impaired care.
A resident with COPD, diabetes, Sjogren's syndrome, and epilepsy developed a productive cough and coarse lung sounds. Despite notifying the physician on two occasions, the facility failed to ensure timely follow-up, resulting in a delayed response and treatment. The resident was eventually prescribed azithromycin for bronchitis, but the delay placed them at risk for further complications.
A facility failed to ensure a low air-loss mattress was functioning for a resident with multiple diagnoses, leading to a fall. Another resident with Alzheimer's disease was not assessed for safe recliner use or provided with updated toileting interventions after falls. The facility did not implement necessary interventions, placing residents at risk for further falls.
A facility failed to monitor and document a dialysis resident's fluid restriction, as ordered by a physician. The resident, with end-stage renal disease, was on a 1200 ml daily fluid restriction, but records lacked evidence of monitoring. Staff interviews revealed a lack of awareness and documentation of the resident's fluid intake, and the facility did not provide a policy on fluid restriction.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying trauma-based triggers or implementing individualized interventions. Despite having a trauma care plan, staff were unaware of the resident's PTSD diagnosis or potential triggers, and the care plan lacked specific interventions. This placed the resident at risk for decreased psychosocial well-being and ineffective treatment.
Two residents received blood pressure medications outside physician-ordered parameters, risking physical decline. One resident with multiple health conditions was given amlodipine, hydralazine, hydrochlorothiazide, and losartan despite low DBP readings. Another resident with Alzheimer's and other conditions received lisinopril outside parameters. The facility lacked a policy for administering these medications.
Two residents were administered the antipsychotic medication quetiapine without an approved diagnosis or physician-documented rationale, including risk versus benefit. Despite facility policies emphasizing non-pharmacological interventions for dementia-related behaviors, records for both residents lacked necessary documentation. Staff interviews confirmed awareness of the inappropriate use of psychotropic medications for dementia, yet no attempts were made to justify or change the medication use.
The facility failed to ensure proper collaboration with hospice services for two residents receiving end-of-life care. The care plans for both residents lacked specific details about hospice services, such as contact information, supplies, medications, and staff visit schedules. This deficiency placed the residents at risk of inadequate care, despite the facility's policy to maintain high-quality palliative care.
A cognitively impaired resident was sexually abused by another resident in a LTC facility. Despite previous observations of inappropriate contact, the facility failed to update care plans or document behavior issues, leading to an incident where a CNA observed the abuse. The facility's policy on abuse was not effectively implemented.
A cognitively impaired resident was not protected from sexual abuse by another resident with a history of inappropriate touching. Despite multiple observations of inappropriate behavior, the facility failed to update care plans or document incidents, leading to a deficiency.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding facility-initiated transfers or discharges to hospitals. This deficiency was identified for several residents, including those with complex medical conditions such as chronic respiratory failure, congestive heart failure, and diabetes mellitus. The lack of written notification extended to the State Long Term Ombudsman, which is a requirement for ensuring residents' rights and informed care choices. For instance, one resident with multiple diagnoses, including urinary tract infections and acute kidney failure, was transferred to the hospital multiple times without receiving written notification of the transfer. The facility's records lacked evidence of any written communication to the resident or their representative, and the facility's staff confirmed that the process had changed under new administration, leading to the discontinuation of such notifications. Similarly, other residents with conditions like COPD, sepsis, and dementia were also transferred to hospitals without receiving the required written notifications. Interviews with facility staff revealed a systemic issue where the responsibility for providing written notifications was unclear, and the facility's policy on emergency transfers was not being followed. This failure to notify placed residents at risk for uninformed care choices and impaired their rights.
Failure to Provide Bed Hold Policy Upon Hospital Transfers
Penalty
Summary
The facility failed to provide six residents with written information regarding the facility's bed hold policy when they were transferred to the hospital. This deficiency was identified through observations, record reviews, and interviews. The residents affected included those with complex medical conditions such as chronic respiratory failure, congestive heart failure, diabetes, and other serious health issues. The lack of documentation and communication regarding the bed hold policy placed these residents at risk of not being permitted to return to the facility and resume residence. The facility's bed hold policy, dated May 2024, required that residents and their representatives be informed in writing about the facility and state bed-hold policies upon admission. However, the facility did not provide this information upon each transfer to the hospital, as evidenced by the clinical records of the residents. Interviews with administrative and nursing staff revealed that the process had changed with the new administration, and the notification of the bed hold policy was only signed upon admission, not during subsequent transfers. Specific cases highlighted in the report include residents who were transferred multiple times to the hospital for various medical emergencies, such as urinary tract infections, respiratory distress, and possible transient ischemic attacks. Despite these transfers, there was no evidence in the clinical records that the bed hold policy was provided to the residents or their representatives. This oversight was confirmed by staff interviews, where it was acknowledged that the policy was not reissued upon each hospital transfer, contrary to the facility's documented policy requirements.
Consultant Pharmacist Fails to Identify Medication Administration Errors
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication administration outside of physician-ordered parameters for several residents. Resident 1 received lisinopril, a blood pressure medication, outside the prescribed parameters multiple times over three months. Despite the physician's order to hold the medication if the diastolic blood pressure (DBP) was less than 60, the medication was administered when the DBP was below this threshold on numerous occasions. The CP's monthly Medication Regimen Reviews (MRR) did not document these irregularities, placing the resident at risk for unnecessary medication use and related complications. Resident 20 was administered quetiapine, an antipsychotic, for a diagnosis of dementia, which is not a CMS-approved indication. The CP initially noted the lack of an appropriate diagnosis and recommended a gradual dose reduction, but the physician did not provide a rationale for the continued use of the medication. Subsequent MRRs by the CP failed to readdress the issue, leaving the resident at risk for unapproved medication use. Similarly, Resident 31 was prescribed Seroquel, another antipsychotic, for dementia without a documented clinical rationale or approved indication. The CP did not identify or report this deficiency in the MRRs. Resident 18 received multiple blood pressure medications, including amlodipine, hydralazine, hydrochlorothiazide, and losartan, outside the physician-ordered parameters. The medications were administered when the DBP was below the specified threshold, contrary to the physician's orders. The CP's MRRs from October to December did not identify or report these discrepancies. The facility's policy required the CP to review medication regimens monthly and communicate any potential or actual problems to the responsible physician and the Director of Nursing, which was not adhered to in these cases.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate during the survey. The incident involved a resident with multiple diagnoses, including cerebral infarction, hemiparesis, COPD, diabetes mellitus, dementia, and hypertension. The resident's care plan required careful administration of medications, including those with Black Box Warnings, and monitoring of blood pressure parameters before administering antihypertensive medications. On the day of the incident, a Certified Medication Aide (CMA) administered the resident's morning medications, including several blood pressure medications, without adhering to the physician-ordered parameters. The resident's diastolic blood pressure was below the threshold specified in the physician's orders, but the CMA proceeded with the administration. The CMA later acknowledged the error upon reviewing the parameters. The facility did not provide a policy for medication errors, contributing to the observed deficiency.
Improper Storage and Monitoring of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and monitoring of medications and biologicals in one of its two medication rooms, which placed residents at risk of receiving ineffective medication. During an observation, it was found that the East medication room had two refrigerators, and the temperatures for these refrigerators were not assessed and recorded for nine out of 17 days in December 2024. Additionally, one refrigerator contained 24 Activa yogurts with expiration dates ranging from September 2024 to November 2024. Licensed Nurse J confirmed the lack of temperature documentation and disposed of the expired yogurts. Administrative Nurse D verified that the refrigerator temperatures should be recorded daily by the night shift nursing staff. The facility did not provide a policy related to the storage of medication and biologicals.
Failure to Develop Comprehensive Care Plans for Dialysis and Diabetes Management
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as R29, who required dialysis care. R29's electronic medical record documented diagnoses of end-stage renal disease, diabetes mellitus, and hypertension, among others. Despite these conditions, R29's care plan did not include a focus or staff direction for dialysis care. Observations revealed that R29 was not compliant with her fluid restriction, a critical component of dialysis care, as she was seen with a large mug and a supply of soda pop in her room. Interviews with staff, including a CNA and a licensed nurse, confirmed the absence of dialysis care interventions in R29's care plan. Another resident, identified as R36, also lacked a comprehensive care plan addressing diabetes mellitus and insulin use. R36's medical record included diagnoses such as type 2 diabetes with ketoacidosis, cerebral infarction, and chronic pain syndrome. Despite receiving insulin and other medications, R36's care plan did not provide guidance for managing diabetic conditions and insulin use. A history and physical note indicated a history of severely uncontrolled diabetes, and the resident had been admitted to the ICU for an insulin drip due to diabetic ketoacidosis. Interviews with administrative staff confirmed the absence of diabetic care guidance in R36's care plan. The facility's policy required individualized, interdisciplinary care plans based on residents' needs, strengths, limitations, and goals. However, the facility failed to ensure that care plans for R29 and R36 included necessary interventions for dialysis and diabetes management, respectively. This oversight placed both residents at risk of impaired care due to uncommunicated care needs.
Failure to Follow Up with Physician for Resident's Respiratory Symptoms
Penalty
Summary
The facility failed to follow up with the physician for a resident, identified as R10, who became ill with a productive cough and coarse lung sounds. R10 had a medical history of chronic obstructive pulmonary disease (COPD), diabetes mellitus, Sjogren's syndrome, and epilepsy. The resident was on hospice care and required oxygen therapy. On 06/17/24, a nurse documented that R10 had a productive cough with thick green sputum and notified the physician, but there was no follow-up documented in the Electronic Medical Record (EMR) when the physician did not respond. On 06/24/24, another nurse noted that R10 had a harsh cough with coarse lung sounds and sent a second fax to the physician requesting a chest X-ray and other interventions. The physician responded on 06/24/24, asking how long R10 had symptoms and scheduled an appointment for 07/03/24. The physician's order on 07/03/24 directed the administration of azithromycin for bronchitis. Interviews with staff revealed that the physician was difficult to reach, and the facility's policy required timely communication of medical care problems. The lack of follow-up placed R10 at risk for physical decline and complications due to delayed physician involvement.
Failure to Ensure Functioning Equipment and Assess Resident Needs
Penalty
Summary
The facility failed to ensure that a low air-loss mattress for a resident with multiple diagnoses, including Parkinson's disease, dementia, and a history of falls, was functioning properly. This resident, who was on hospice care and had severely impaired decision-making skills, was found face down on the floor next to his bed with the mattress unplugged. The incident resulted in a bruise and bleeding on the resident's right knee and toe. Staff interviews revealed that the mattress was not turned on, and the bed did not have bolsters at the time of the fall, despite the resident being assessed as high risk for falls. Another resident with Alzheimer's disease and a history of falls was not assessed for the safe use of a recliner or provided with updated toileting interventions after sustaining multiple falls. This resident, who had severely impaired cognition and was frequently incontinent, was not on a toileting plan despite several falls related to attempts to reach the bathroom. The resident was found to have fallen multiple times, including sliding out of a recliner and scooting across the floor to the bathroom without activating the call light. The facility's policies required that residents be provided with an environment free from accident hazards and that fall risk assessments and interventions be implemented. However, the facility failed to implement necessary interventions for the resident using the recliner and did not identify toileting needs as a causative factor for repeated falls. This oversight placed the resident at risk for further falls and injury.
Failure to Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident's physician-ordered fluid restriction was followed, monitored, and documented. The resident, who had end-stage renal disease and was dependent on dialysis, was on a fluid restriction of 1200 milliliters daily. However, the facility's records, including the Treatment Administration Record and Progress Notes, lacked evidence of monitoring and documentation of the resident's daily fluid intake. The resident admitted to not following the fluid restriction and keeping a supply of soda in her room, which was not accounted for by the staff. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's fluid restriction. A Certified Nurse Aide was uncertain about the resident's fluid restriction status, while a Licensed Nurse and an Administrative Nurse acknowledged the resident's non-compliance and the absence of documentation. The facility did not provide a policy regarding fluid restriction when requested, further indicating a deficiency in managing the resident's fluid intake, which placed the resident at risk of fluid overload and related complications.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as they did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization. The resident, who also had a history of cerebrovascular accident and hemiplegia, was documented to have intact cognition and impaired hearing. Despite having a trauma care plan initiated, the plan lacked specific interventions to address potential triggers, and staff were unaware of any triggers or the cause of the resident's PTSD. Observations and interviews revealed that staff, including a CNA and a licensed nurse, were not informed about the resident's PTSD diagnosis or potential triggers. The facility's trauma-informed care policy emphasized the importance of identifying and managing trauma-related triggers, yet the resident's care plan did not reflect this. The administrative nurse confirmed that the care plan lacked information about the resident's traumas or possible triggers, which placed the resident at risk for decreased psychosocial well-being and ineffective treatment.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering blood pressure medications to two residents, R18 and R1, which placed them at risk for physical decline and other related complications. For R18, the facility's staff administered multiple blood pressure medications, including amlodipine, hydralazine, hydrochlorothiazide, and losartan, despite the resident's diastolic blood pressure (DBP) being below the ordered parameters on numerous occasions across October, November, and December 2024. The Certified Medication Aide (CMA) responsible for administering these medications admitted to not being aware of the specific parameters and mistakenly gave the medications when the DBP was out of range. R18's medical history included conditions such as cerebral infarction, hemiparesis, chronic obstructive pulmonary disease (COPD), diabetes mellitus, dementia, and hypertension. The resident was dependent on staff for various activities of daily living and had intact cognition. Despite these complexities, the facility did not provide a policy for administering blood pressure medications or for checking blood pressure parameters, leading to the repeated administration of medications outside the prescribed limits. Similarly, R1, who had diagnoses including Alzheimer's disease, muscle weakness, major depressive disorder, and COPD, received lisinopril outside the physician-ordered parameters multiple times in October, November, and December 2024. The facility's failure to hold the medication when R1's blood pressure was below the specified parameters was confirmed by the Administrative Nurse. Like R18, R1's care plan included monitoring for complications due to medications with Black Box Warnings, yet the facility lacked a policy to guide staff in administering blood pressure medications according to physician orders.
Failure to Document Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that two residents, R20 and R31, had an approved diagnosis or a physician-documented rationale, including risk versus benefit, for the use of the antipsychotic medication quetiapine. This deficiency was identified through observation, record review, and interviews. R20's electronic medical record included multiple diagnoses, such as insomnia, mood disorder, unspecified dementia, and anxiety disorder. Despite receiving quetiapine for dementia-related behavioral disturbances, R20's records lacked evidence of a physician-documented rationale for the medication's use. The facility's policy emphasized the inappropriate use of psychopharmacologic medications for dementia-related behaviors, advocating for non-pharmacological interventions instead. Similarly, R31's records documented diagnoses of dementia with behavioral disturbances, major depressive disorder, and bipolar disorder. R31 received quetiapine for dementia, but the clinical records lacked a physician's documented rationale for its continued use. The facility was unable to provide this information upon request. Interviews with staff revealed awareness of the inappropriate use of psychotropic medications for dementia, yet there was no evidence of attempts to change the diagnosis or justify the medication's use. The facility's undated Psychotropic Medication Monitoring policy stated the importance of complying with state and federal regulations regarding psychopharmacological medications, including regular reviews for continued need and appropriate dosage. However, the facility failed to ensure that both R20 and R31 had a CMS-approved indication or the required physician documentation for the use of antipsychotic medications, placing them at risk for unnecessary medication administration and possible adverse side effects.
Failure to Ensure Collaboration with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration between hospice providers and the facility for two residents, R10 and R42, who were receiving hospice services. R10, who was admitted to hospice on October 1, 2024, had a care plan that lacked specific details about the hospice services, such as contact information, supplies, medications, and the schedule of hospice staff visits. Despite the care plan directing staff to work cooperatively with the hospice team, these omissions placed R10 at risk of inadequate end-of-life care. Observations and interviews revealed that while hospice services were being provided, the care plan did not reflect the necessary details to ensure comprehensive care. Similarly, R42, who was admitted to hospice on October 25, 2024, had a care plan that failed to include specific instructions on how to collaborate with hospice services. The care plan did not detail the supplies and medications provided by hospice or the schedule of hospice staff visits. Although R42's hospice binder contained a plan of care, this information was not integrated into the care plan, leading to potential gaps in care coordination. Interviews with staff indicated a lack of clarity on hospice information being included in the care plan, which could affect the quality of care provided. The facility's policy on End of Life, Palliative, and Hospice Care, revised in May 2024, stated that the facility would maintain a relationship with hospice to ensure continuity of high-quality palliative care. However, the lack of detailed care plans for R10 and R42 demonstrated a failure to adhere to this policy, resulting in a deficiency that placed both residents at risk of inadequate end-of-life care.
Failure to Prevent Sexual Abuse of Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent the sexual abuse of a cognitively impaired resident, identified as R3, who lacked the ability to consent. On a specific date, a Certified Nurse Aide (CNA) observed another resident, R2, who was cognitively intact, with his hand inside R3's pant leg up to her groin area. R3 had severe cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of three, and required staff supervision for mobility. The incident placed R3 in immediate jeopardy and at risk for trauma and a negative psychosocial impact. Prior to the incident, there were multiple observations and reports of R2 engaging in inappropriate physical contact with R3. These included touching R3's knee and arm, and R3's apparent discomfort and attempts to avoid R2's reach. Despite these observations, the facility's care plans for both residents lacked interventions related to preventing such contact. R2's care plan did not address any behavior issues, and R3's care plan did not include measures to protect her from unwanted touching by R2. The facility's response to previous reports of R2's behavior was inadequate. Although staff had observed and reported R2's inappropriate contact with R3, there was no documentation of behavior issues in R2's chart, and the care plans were not updated to reflect necessary interventions. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to prevent the incident of sexual abuse involving R3.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident, R3, from sexual abuse by another resident, R2, who was cognitively intact. R2, who had a history of inappropriate touching, was observed by a CNA with his hand inside R3's pant leg up to her groin area. R3, who had severe cognitive impairment and was unable to consent, was placed in immediate jeopardy due to this incident. The facility's care plan for R2 did not include any interventions related to his behavior, and there was a lack of documentation regarding his inappropriate actions. Prior to the incident, there were multiple observations and reports of R2's inappropriate behavior towards R3, including touching her knee and arm. Despite these observations, the facility did not update R2's care plan to address these behaviors, nor did they document these incidents in R2's progress notes. Staff members, including CNAs and administrative staff, witnessed these interactions but failed to take adequate action to prevent further occurrences. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the lack of documentation and intervention regarding R2's behavior. The facility's failure to protect R3 from sexual abuse and to document and address R2's inappropriate behavior resulted in a deficiency, placing R3 at risk for trauma and negative psychosocial impact.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 165 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Dorado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| El Dorado Care And Rehab | 2.7 mi | ★★★★★ | 22 | 0 |
| Lakepoint Augusta, Llc | 9.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Andover | 16.2 mi | ★★★★★ | 4 | 4 |
| Avita Health And Rehab At Reeds Cove | 18.7 mi | ★★★★★ | 11 | 0 |
| Wheat State Manor | 18.9 mi | ★★★★★ | 29 | 0 |
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