Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eldorado Rehab & Healthcare during CMS and state inspections, most recent first.
A resident with multiple complex diagnoses was admitted without a comprehensive, person-centered care plan in place. The care plan in the EHR only addressed advanced directives and long-term residency, and staff confirmed that a complete care plan was never developed or made accessible to guide care.
Three residents who required assistance with bathing did not consistently receive showers as scheduled or preferred, with documentation and resident interviews confirming missed or delayed showers. Staff and policy indicated an expectation of at least two showers per week, but records showed irregularities and lack of proper documentation for refusals, resulting in unmet hygiene needs for these residents.
A resident with significant mobility impairments had bed rails attached to her bed frame using zip ties instead of the manufacturer's recommended method, as the rails were not compatible with the new bed. Staff and maintenance confirmed the use of zip ties as a temporary solution, and the rails were observed to be loose and unstable, contrary to facility policy requiring proper installation.
A resident with Alzheimer's dementia and severe cognitive impairment was admitted and required maximum assistance for all ADLs, but did not have a comprehensive care plan addressing dementia care. The care plan only included advanced directives and long-term residency, and staff confirmed it was incomplete and lacked necessary interventions for cognitive decline.
The facility failed to ensure safe medication administration for two residents. One resident, who was cognitively intact, was found with Nystatin Powder on her bedside table without current orders or an assessment for self-administration. Another resident, with moderate cognitive impairment, had medications left at her bedside by a nurse, contrary to facility policy. The facility's policies require assessments for self-administration, but no evidence of such assessments was found.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident following admission. The resident was admitted with multiple diagnoses, including dementia, Alzheimer's dementia, acute kidney failure, urinary tract infection, atrial flutter, diverticulosis, diabetes mellitus type 2, and general anxiety disorder. Review of the electronic health record revealed that the care plan only included two focus areas: advanced directives and long-term residency, with no evidence of a complete or dated care plan. Staff interviews confirmed that the care plan was never fully developed, and any baseline care plan that may have existed was not accessible to staff for guiding care. The Director of Nursing and the Care Plan Coordinator both acknowledged the absence of a comprehensive, individualized care plan for the resident after admission.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents requiring assistance with bathing received showers at the frequency scheduled or preferred, as evidenced by interviews, observations, and record reviews for three residents. One resident, admitted with cerebral infarction and hemiplegia, was cognitively intact and reported not receiving the scheduled two showers per week, often going seven or eight days between showers. Documentation confirmed that this resident received only 12 out of 20 scheduled showers over a two-month period, with only two documented refusals. Another resident, dependent on staff for all activities of daily living due to severe cognitive and physical impairment, was observed with very dry, flaky skin on multiple occasions. Records showed this resident did not consistently receive scheduled showers, with some bed baths substituted, despite staff confirming that residents are expected to receive two showers per week according to the facility's schedule. A third resident, also cognitively intact and requiring substantial assistance for bathing, was observed with greasy, unkempt hair and reported not receiving showers on time, often only once per week. Documentation indicated irregular shower frequency, not consistently matching the scheduled days. The facility's policy requires at least one complete bath and hair wash weekly, with additional baths as necessary for personal hygiene. Staff interviews confirmed the expectation of twice-weekly showers, and that refusals should be documented, but the records and resident reports indicated this was not consistently followed.
Improper Installation of Bed Rails Using Zip Ties
Penalty
Summary
The facility failed to ensure that bed rails were installed in accordance with the manufacturer's recommendations and specifications for one resident. The resident, who had a history of muscle weakness, unsteadiness, reduced mobility, cerebral infarction, and hemiplegia, required substantial to maximal assistance with mobility and used bed rails to reposition herself. Upon admission to a new room, the resident's previous bed rails were attached to the new bed frame using zip ties instead of being bolted, as they were not compatible with the new bed. Staff and the maintenance supervisor confirmed that the rails were not designed for the current bed and that zip ties were used as a temporary measure until the correct rails arrived. The bed rails were observed to be loose and unstable, and the facility did not have the manufacturer's instructions for the bed. The resident and staff reported that the bed rails were necessary for the resident's mobility and repositioning in bed. Despite this, the rails remained improperly attached for several days, as confirmed by multiple observations and interviews. The facility's own policy required that bed rails be installed according to the manufacturer's instructions to ensure safety, but this was not followed, resulting in the deficiency.
Failure to Develop Dementia Care Plan for Resident with Alzheimer's
Penalty
Summary
A resident admitted with a diagnosis of Alzheimer's dementia and severe cognitive impairment did not have a comprehensive care plan developed to address her dementia or cognitive decline. The resident's Minimum Data Set documented severe cognitive impairment and a need for maximum to total assistance with all activities of daily living. However, the care plan only included focus areas for advanced directives and long-term residency, with no documented plan for treatment or services related to dementia. Interviews with facility staff, including the Care Plan Coordinator, Director of Nursing, and Corporate Nurse, confirmed that the care plan was incomplete and lacked necessary interventions for the resident's cognitive condition.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure safe medication administration for two residents, R2 and R3, as observed during the survey. R2, who is cognitively intact with a BIMS score of 15, was found with a bottle of Nystatin Powder on her bedside table, which she applied herself. The medication was not included in her current orders, and there was no documentation of an assessment for her ability to self-administer medications. The Director of Nursing (V2) acknowledged that R2 was alert and oriented but did not confirm if the physician was aware of R2's continued use of the medication beyond the prescribed period. R3, who has moderate cognitive impairment with a BIMS score of 9, was found with a medication cup containing pills on her bedside table. The Registered Nurse (V8) admitted to leaving the medications there because R3 preferred to take them after eating. This practice was against the facility's policy, which requires medications to be administered directly and not left at the bedside unless ordered by a physician. V8 confirmed that the medications were the 12 PM doses of Sulfasalazine and Carbidopa-Levodopa, which were left in R3's room. The facility's policies on medication administration and self-administration require that residents can only self-administer medications if assessed and deemed capable by the interdisciplinary team and physician. However, there was no evidence of such assessments for R2 and R3. The Director of Nursing was unsure if these assessments were documented in the electronic health record system. The facility's failure to adhere to its policies resulted in medications being left at the bedside without proper authorization or assessment of the residents' ability to self-administer safely.
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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.
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Nursing homes near Eldorado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saline Care Nursing & Rehab | 8 mi | — | 0 | 0 |
| Axiom Healthcare Of Harrisburg | 8.5 mi | — | 4 | 0 |
| Gallatin Manor | 9.7 mi | — | 19 | 0 |
| Carrier Mills Nsg & Rehab Ctr | 13.3 mi | — | 10 | 0 |
| Silver Foxes Sr Living & Rehab | 19.7 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.