Eldora Specialty Care

In the surveyor’s words

From the most serious findings on record at Eldora Specialty Care, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 15, 2026

  Based on clinical record review, facility investigation review, staff interviews and policy review, the facility failed to protect residents from verbal and physical abuse by a staff member for 3 of 3 residents reviewed for abuse (Residents #1, #5, #6). The facility reported a census of 36 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS identified Resident #1 required substantial or maximal assistance with showering and bathing and depended on staff for tub or shower transfers. […]

• Actual harm, isolatedF689Jun 24, 2021

  Based on observations, facility policy review and staff interviews, the facility failed to ensure supervision of residents during administration of medication and safe transfer assistance for 4 of 6 residents reviewed (Resident's #9, #11, #19 and #32). The facility reported a census of 34 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had diagnoses of diabetes mellitus (DM), malnutrition and asthma. The MDS revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The MDS further revealed Resident #19 required one person physical assist locomotion on and off the unit, dressing and toilet use. […]

• No harm, potential for more than minimal, patternF550Jun 24, 2021

  Based on clinical record review, observation, staff interview, and resident interview, the facility failed to provide privacy of a body during personal cares for 1 out of 1 sampled residents observed for cares, (Resident #30) and failed to provide privacy by not knocking on the door before entering the room for 6 of 9 residents. The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 30 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the Brief Interview for Mental Status (BIMS) was not completed. On 6/22/21 at 2:34 p.m., Staff M, Certified Nursing Assistant (CNA) entered Resident # 30's room and assisted her with getting a drink of water and repositioning her head. […]

• No harm, potential for more than minimal, patternF880Jun 24, 2021

  Based on observations, staff interview, and record review, the facility failed to provide appropriate infection control standards for 11 residents of 11 residents observed. The facility reported a census of 35 residents. Findings include: 1. Observation on 6/22/21 at 2:39 p.m., revealed Staff N, housekeeping staff, delivering laundry to rooms in hallway A. Laundry cart with clean clothing was sitting in the hallway uncovered. Staff N, housekeeping staff, came out of the room and proceeded to push the cart down the hallway uncovered to the next room. Staff N, housekeeping staff, took the clothing off of the rack and placed them under their arm against their uniform and walked into the room and placed residents' clothing into the closet. 2. […]

• No harm, potential for more than minimal, isolatedF580Jun 15, 2026

  Based on clinical record review, staff interviews and policy review, the facility failed to notify the Physician and family of an allegation of abuse for 2 of 2 resident reviewed (Resident #1 and #5). The facility reported a census of 36 residents.Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. The MDS identified Resident #1 required substantial or maximal assistance with showering and bathing and depended on staff for tub or shower transfers. […]