Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 The Springs Of El Dorado during CMS and state inspections, most recent first.
A resident with peripheral vascular disease, prior toe amputation, and malnutrition had multiple lower extremity wounds managed by an external Wound Care Clinic, which issued detailed written orders for cleansing, specific dressings, and compression. Facility TAR entries showed generalized leg treatments on a fixed schedule instead of the ordered every-other-day frequency, did not distinguish between multiple wounds on the same leg, omitted documentation of ordered transfer foam and a compression stocking, and added self-adherent wrap that was not ordered. Interviews with the TN and DON confirmed that the TN was responsible for entering and carrying out clinic orders, and leadership could not produce documentation that all ordered treatments were provided or explain the altered treatment frequency, contrary to facility policy requiring treatments to follow provider orders.
A resident with COPD, anxiety disorder, malnutrition, and a history of alcohol abuse in remission, who was receiving benzodiazepine anti‑anxiety medication and had no order or care plan allowance for alcohol, was found multiple times to have consumed alcohol in the facility. CNAs and LPNs discovered empty and full alcohol bottles in the resident’s room and observed the resident appearing drunk, groggy, confused, lethargic, and slurring words, with noted balance and behavioral changes. The APRN documented increased drowsiness, equilibrium concerns, and later confusion and auditory disturbances, and held the anti‑anxiety medication after learning of intoxication. The DON and Administrator reported that the resident identified a CNA as the source of the alcohol, and the CNA admitted to bringing alcohol to the resident on two occasions, resulting in intoxication within the facility, contrary to the resident’s orders and care plan.
The facility did not provide required written notification of bed-hold policies, appeal rights, or advocacy contact information to residents or their representatives when three residents with cognitive impairments and complex medical needs were transferred to the hospital. Staff interviews and record reviews confirmed that the necessary documentation and notifications were not completed or sent due to lapses in following established procedures.
Surveyors identified multiple deficiencies in food storage, sanitation, and hand hygiene. Opened food items were left uncovered in the refrigerator, freezer, and storage areas, and expired food was not promptly discarded. The ice machine had visible residue, and kitchen surfaces showed grease buildup. A dietary aide failed to wash hands between handling dirty and clean items, contrary to facility policy. These actions did not meet professional standards for food safety and sanitation.
The facility failed to supervise residents while smoking, leading to increased potential for injury. Two residents, both documented as requiring supervision, were observed smoking without supervision. The CNA responsible was unaware of the care plans and left the residents unattended, contrary to the facility's smoking policy.
Failure to Follow Wound Clinic Orders for Lower Extremity Wounds
Penalty
Summary
The deficiency involves the facility’s failure to complete and follow wound care provider orders for one resident with multiple lower extremity wounds. The resident was admitted with diagnoses including peripheral vascular disease, acquired absence of a right toe, and malnutrition, and was documented as alert, oriented, and cognitively intact. The resident received wound care at an external Wound Care Clinic, which issued detailed written orders on two separate dates for multiple wounds on both lower legs, specifying cleansing with normal saline, use of transfer foam or autolytic debridement gel, specific secondary dressings, soft cloth surgical tape, sterile roll gauze, gauze sponges, and, for one right lower leg wound, a compression stocking. Review of the facility’s Treatment Administration Record (TAR) for the same period showed that the treatments documented did not match the clinic’s orders. The TAR listed generalized treatments for the left and right lower legs, including cleansing with normal saline, gauze to the wound bed, and application of self-adherent wrap from toes to bend of leg on a Tuesday, Thursday, Saturday schedule, rather than every other day as ordered. Later TAR entries for bilateral extremities referenced autolytic debridement gel, auto debridement dressing, and elasticated tubular bandage, but still did not clearly distinguish between the multiple wounds on the right lower leg or document all ordered components. There was no distinction on the TAR to ensure both right lower leg wounds were treated, no documentation that transfer foam was applied as ordered, and no documentation that the ordered compression stocking was applied to the specified right lower leg wound. Interviews and record review confirmed these discrepancies and the lack of supporting documentation. The Treatment Nurse described a process in which Wound Care Clinic orders were faxed to the facility, compiled, and then entered onto the TAR by the Treatment Nurse after leadership meetings or by the end of the business day. The DON stated that it was the Treatment Nurse’s responsibility to ensure clinic orders were completed and acknowledged that wounds could deteriorate if not treated per provider orders. During a joint interview, the DON, Administrator, and Nurse Consultant were unable to provide any documentation that the transfer foam treatment was given as ordered or any explanation for why every-other-day orders were carried out on a fixed Tuesday, Thursday, Saturday schedule. Facility policy on Medication and Treatment Orders required that medications be administered per the written order of a licensed provider, which was not followed in this case.
Failure to Prevent Staff-Supplied Alcohol Use in a Resident on Anti-Anxiety Medication
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe care environment and to follow treatment parameters for a resident with a documented history of alcohol abuse (in remission) and active use of anti‑anxiety medications. The resident was cognitively intact per a recent MDS, had diagnoses including COPD, anxiety disorder, malnutrition, and alcohol abuse in remission, and had no care plan allowance or provider order permitting alcohol consumption. The care plan specifically noted the risks of abuse, misuse, and serious adverse outcomes when benzodiazepines are used with alcohol or other substances. Despite this, the resident obtained and consumed alcohol within the facility. On one weekend, CNAs found four empty alcohol bottles under the resident’s sink, and an LPN documented that the resident appeared drunk. Another LPN later witnessed the resident actively drinking from an alcohol bottle and, upon searching the room, found two more bottles. In the days surrounding these events, clinical notes described the resident as significantly more drowsy than normal, groggy, a little confused, and having possible equilibrium problems, with slurred and delayed speech. The APRN documented that the resident’s anti‑anxiety medication dose had been increased at one point due to reported depression and later ordered the medication held after learning the resident had become intoxicated. Subsequently, the resident’s roommate reported that the resident had trouble walking and was showing unusual irritation, and expressed concern about the resident’s safety while acknowledging awareness of the resident’s alcohol possession. A later APRN note described the resident as lethargic, slurring words, unable to recall a prior lengthy conversation, confused/incoherent, grimacing, and reporting auditory echoing and altered sound perception. During interviews, the DON and Administrator reported that the resident later admitted that a CNA had been supplying the alcohol, and the CNA ultimately confessed to bringing alcohol to the resident on two occasions, which resulted in the resident consuming large amounts of alcohol and becoming intoxicated in the facility. The facility’s failure to prevent staff from supplying alcohol and to ensure the resident did not consume alcohol contrary to orders and care plan restrictions led to the identified deficiency.
Failure to Provide Required Written Notification of Bed-Hold Policy and Appeal Rights During Hospital Transfers
Penalty
Summary
The facility failed to provide required written notification and information regarding bed-hold policies, appeal rights, and contact information for advocacy agencies to residents and/or their representatives when residents were transferred to the hospital. This deficiency was identified for three out of four sampled residents who were hospitalized. The facility's own policies required that, prior to transfer, residents and their representatives be informed in writing of the bed-hold and return policy, as well as their appeal rights and contact information for the Ombudsman and relevant advocacy agencies. For one resident with moderate cognitive impairment and multiple medical diagnoses, including diabetes, dementia, and respiratory failure, the record showed that the resident was transferred to the hospital after a significant change in condition. However, the facility was unable to provide evidence that the required Notice of Transfer/Bed Hold was sent to the resident or their representative. Interviews with facility staff revealed that the process for triggering the notification was not consistently followed, as the necessary documentation in the electronic health record was not completed by the responsible nurses. Similar deficiencies were found for two other residents, one with moderate cognitive impairment and intellectual disabilities, and another with severe cognitive impairment and multiple medical conditions. In both cases, the facility could not provide evidence that the residents or their representatives received complete information regarding their rights, the bed-hold policy, or contact information for advocacy agencies at the time of hospital transfer. Staff interviews confirmed that the required notifications were not sent due to incomplete documentation and lack of adherence to established procedures.
Deficiencies in Food Storage, Sanitation, and Hand Hygiene Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and sanitation practices within the facility. Opened boxes of sausage patties and fish were found in the refrigerator and freezer without being covered or sealed. An opened box of crackers with an expired date was present in the storage room, and an opened box of salt was left uncovered above a food preparation counter. The Dietary Manager acknowledged these issues, noting the potential for freezer burn and pest contamination. Additionally, the floor between the deep fryer and oven had a significant grease buildup, and the inside corners of the ice machine contained a wet, blackish residue that could be wiped off, indicating inadequate cleaning frequency. The Maintenance Director stated that the ice machine was being cleaned weekly due to rapid dirt accumulation. Dietary staff were also observed failing to follow proper hand hygiene protocols. One dietary aide used a rag to clean up food spills, handled dirty dishes, and then moved to the clean side to handle clean equipment and prepare food without washing her hands in between tasks. Facility policies reviewed indicated that hands should be washed before starting work with food, before putting on gloves, and as often as needed during food preparation and when changing tasks. The facility's food storage policy also required all foods to be stored wrapped or in covered containers to prevent cross-contamination, which was not consistently followed.
Failure to Supervise Residents While Smoking
Penalty
Summary
The facility failed to ensure residents on the secured unit were supervised while smoking, which increased the potential for injury. Resident #37, diagnosed with Alcohol-Induced Persisting Dementia, was documented as requiring supervision while smoking. However, on multiple occasions, Resident #37 was observed smoking without supervision. Certified Nursing Assistant (CNA) #2 provided Resident #37 with a cigarette, lit it, and left the resident unattended in the smoking area. This was contrary to the resident's care plan and the facility's smoking policy, which required supervision during smoking times. Similarly, Resident #71, who had diagnoses including Suicidal Ideations, Seizures or Convulsions, and Bipolar Disease, was also documented as requiring supervision while smoking. Despite this, CNA #2 allowed Resident #71 to smoke without supervision. CNA #2 was unaware of the residents' care plans and the requirement for supervision, leading to multiple residents being left unattended while smoking. The Director of Nursing confirmed that residents on the secured unit were not allowed to smoke without supervision, and the facility's smoking policy mandated supervision to ensure safety.
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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 El Dorado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Ridge Health And Rehabilitation | 0.2 mi | ★★★★★ | 2 | 0 |
| Timberlane Health & Rehabilitation | 1.4 mi | ★★★★★ | 1 | 0 |
| Hudson Memorial Nursing Home | 2 mi | ★★★★★ | 1 | 0 |
| Courtyard Rehabilitation And Health Center, Llc | 3.1 mi | ★★★★★ | 4 | 0 |
| Silver Oaks Health And Rehabilitation | 26.9 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.