Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eldora Specialty Care during CMS and state inspections, most recent first.
Failure to Protect Residents from Abuse: A CNA/CMA was witnessed yelling at and physically restraining a resident during shower care after the resident resisted, including grabbing the resident’s wrists and pushing her hands to her chest while the resident cried out that it hurt. Two other residents with behavioral concerns were also involved in separate incidents where the same staff member was reported to have grabbed a resident after being hit and scolded another resident over a recliner issue, with one resident describing the interaction as verbal abuse. The facility did not timely report the abuse allegation to DIAL or law enforcement for the incidents described.
Failure to Notify Physician and Family of Abuse Allegations: Two residents with severe cognitive impairment were involved in abuse allegations during care. One resident was reportedly grabbed, had a wrist forcefully pushed into the chest, and was yelled at and threatened during a shower; the other resident was reported to have punched a staff member, after which the staff member grabbed the resident's arm. The record lacked documentation that the attending MD and family were notified for either resident.
Failure to timely report abuse allegations: Staff documented an incident in which a CNA/CMA used physical force during a shower with a combative resident, and leadership did not notify DIAL or law enforcement when the allegation was first reported. A separate allegation involved a resident on the dementia unit who reportedly punched a CNA/CMA, after which the CNA/CMA grabbed the resident’s arm; that incident was also not reported to DIAL or law enforcement. Facility interviews showed leadership debated whether the events were abuse and delayed reporting despite policy requiring immediate notification.
Failure to submit a Level II PASRR evaluation for a resident with a bipolar dx. The resident had severe cognitive impairment, dementia, depression, bipolar disorder, and major depressive disorder on the MDS, and was receiving an antipsychotic, antidepressant, and antianxiety med. The DON acknowledged the bipolar dx was active, appeared on successive MDS assessments, and that the facility did not submit the required Level II PASRR after the new dx was identified.
A resident with intact cognition, no teeth, and no dentures requested a dental visit to discuss dentures, but the facility did not arrange or document any dental care after admission. Social services acknowledged the request and a dental vendor contact, yet no appointment was made and no further steps were documented to obtain routine dental services.
An LPN administered PRN oxycodone via a resident’s PEG tube without applying PPE, despite the resident being on EBP for a PEG tube and tracheostomy stoma. The resident had cancer of the head, face, and neck, depended on staff to eat, and had a care plan directing medications to be given via the PEG tube. The facility policy required PPE for EBP during feeding tube care, and the DON stated EBP was expected during medication administration via a feeding tube.
A facility failed to submit a Level II PASRR evaluation for a resident diagnosed with bipolar disorder. The resident, with intact cognition and a history of behavior problems, was receiving antipsychotic medication. Despite the new diagnosis, the facility did not complete the required evaluation, as acknowledged by the DON, who noted the absence of a policy or protocol for PASRR completion.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by a staff member for 3 of 3 residents reviewed for abuse. Resident #1 had severely impaired cognition with a BIMS score of 3, diagnoses including dementia and senile degeneration of the brain, and was receiving hospice care. Her care plan identified aggressive behavior during ADLs, including hitting staff, yelling, and using foul language, and directed staff to approach her calmly and complete showers quickly because she could become combative. During a shower, Staff A, a CNA/CMA, was documented by multiple witnesses as responding to Resident #1's resistance by yelling at her, grabbing her wrist and forearms, pushing her hands into her chest, and holding her hands against her chest until the shower was finished. Witnesses also reported Staff A slapped Resident #1's hands and made statements such as telling her she would not do this to her and that she would have to stand up on her own to get out of the chair. Resident #1 yelled that it hurt and said Staff A broke her arm. The facility record lacked documentation that the allegation was reported to the attending physician or family, and the facility did not file the abuse allegation with DIAL or notify law enforcement at the time of the incident. Resident #5 also had severely impaired cognition with a BIMS score of 3 and a care plan for behavioral problems, including hitting and scratching staff. Staff A reported that Resident #5 hit her in the back, and witness statements documented Staff A turned around, grabbed Resident #5's right arm, and told her she was not going to touch her. Staff A later said she held Resident #5's hand only to walk with her, but other statements described her as grabbing Resident #5's arm after being struck. The facility did not file an abuse allegation with DIAL or notify law enforcement for this incident. Resident #6 had intact cognition with a BIMS score of 15 and diagnoses including dementia, anxiety, depression, diabetes, and a prior hip fracture. Her care plan noted emotional trauma related to her daughter's death and that she used a recliner in her room. Resident #6 reported that Staff A scolded her repeatedly and spoke to her in a way that made her cry and feel verbally abused when there was a problem with the recliner. Staff A acknowledged making comments about the recliner cord and said Resident #6 became upset and accused her of blaming her. The report reflects that Resident #6 described the interaction as verbal abuse, while staff characterized the exchange as strong wording or a misunderstanding.
Failure to Notify Physician and Family of Abuse Allegations
Penalty
Summary
The facility failed to notify the attending physician and family of allegations of abuse for two residents. Resident #1 had a BIMS score of 3, indicating severe cognitive impairment, and the MDS showed diagnoses including hypertension, non-Alzheimer's dementia, unspecified dementia with other behavioral disturbance, senile degeneration of the brain, and hospice care during the stay. An internal investigation witness statement documented that during shower care, Staff A and other CNAs assisted Resident #1 when the resident became combative, grabbed Staff A, and Staff A responded by grabbing the resident's wrist and aggressively pushing it into the resident's chest. The statement also documented Staff A yelling at the resident, slapping the resident's hands, and making threatening comments during the shower. The record lacked documentation that the allegation of abuse was reported to Resident #1's attending physician or family on the day of the incident. Resident #5 also had a BIMS score of 3 and diagnoses including hypertension, hyperlipidemia, and non-Alzheimer's dementia. A handwritten witness statement documented that Staff A reported Resident #5 punched them in the back, after which Staff A turned around, grabbed the resident's right arm, and told the resident they were not going to touch them. The witness stated the incident was reported to the charge nurse, DON, and Administrator, but the clinical record lacked documentation that the allegation of abuse was reported to Resident #5's attending physician or family. The DON later stated she did not recall staff reporting anything to the resident's family or attending physician.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of abuse to DIAL and law enforcement for two residents. For one resident, a CNA/CMA and two CNAs were involved in a shower on 6/4/26 when the resident resisted care and became combative. A handwritten witness statement documented that the CNA/CMA grabbed the resident’s wrist, pushed it into the resident’s chest, slapped the resident’s hands, and held the resident’s hands against the resident’s chest while the resident yelled that it hurt and that her arm was broken. The same statement documented that staff reported the incident to administration at 3:00 PM that day, but the facility did not file a self-report with DIAL or notify law enforcement at that time. Facility interviews showed that leadership received information about the incident on 6/8/26 and discussed whether the CNA/CMA had defended herself against a combative resident. The DON stated the resident had pulled at the staff member’s shirt and bra and that management felt the staff member defended herself. The acting Administrator stated that 6/8/26 was the first time the allegation came to his attention and that the facility would complete a self-report and investigate. The facility’s self-report was filed later that day, after DIAL had already entered the building and reported an allegation of abuse. The facility policy required abuse allegations to be reported to state agencies and law enforcement. The facility also failed to report an allegation involving another resident on the dementia unit. A handwritten witness statement documented that a CNA/CMA told another CNA that the resident punched her in the back and that she turned around, grabbed the resident’s right arm, and told the resident not to touch her. The witness stated the incident was reported to the charge nurse, DON, and Administrator, but the facility did not file a self-report with DIAL or notify law enforcement. The DON later stated that staff reviewed statements, consulted with management, and decided not to report the incident to DIAL because they did not believe abuse had occurred.
Failure to Submit Level II PASRR for Resident With Bipolar Diagnosis
Penalty
Summary
The facility failed to submit a Level II PASRR evaluation for one resident who had a new mental health diagnosis of bipolar disorder. The resident’s MDS documented severe cognitive impairment with a BIMS score of 3, along with diagnoses including medically complex conditions, non-Alzheimer’s dementia, depression, bipolar disorder, and major depressive disorder. The care plan also identified behavior problems related to unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, and the resident was receiving an antipsychotic, antidepressant, and antianxiety medication during the lookback period. The clinical record showed the bipolar disorder diagnosis became effective and remained active, but no Level II PASRR evaluation was submitted after that diagnosis was added. During interview, the DON acknowledged the resident had an active bipolar disorder diagnosis, that the diagnosis appeared on the MDS and subsequent MDS assessments, and that a new bipolar diagnosis would qualify for a new PASRR. The DON also acknowledged the facility did not submit a Level II PASRR for the resident after the bipolar diagnosis was identified. The facility policy stated that if the Level I PASARR screen indicates a possible mental disorder, intellectual disorder, or related disorder, the individual is referred for the Level II evaluation and determination process.
Failure to Assist Resident With Dental Services
Penalty
Summary
The facility failed to assist one resident in obtaining routine dental care. Resident #10 had a BIMS score of 15, indicating intact cognition, and the MDS documented diagnoses including heart failure, anxiety disorder, depression, and bipolar disorder. The care plan noted the resident ate independently with set-up and needed partial assistance of one for oral hygiene. During interview, the resident stated she had no upper or lower teeth, had no dentures, and wanted a dental appointment to discuss getting dentures. She reported she had been waiting a long time for an appointment and had not seen a dentist since admission to the facility in May 2024. The clinical record contained no documentation of dental services or dental appointments for the resident, despite Medicaid funding being listed. Social Services staff acknowledged the resident requested a dental appointment for dentures and that a dental company comes to the facility, but the resident had not received dental services from that company or any other dental provider since admission. Staff could not identify any completed appointment or additional steps taken after an email from the dental company with treatment authorization and fee information was located. The Administrator stated the facility expected to provide prompt dental services when requested and acknowledged the resident was not promptly provided or assisted with dental needs.
Failure to Use EBP During PEG Tube Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) while administering medication via a peg tube for a resident with malignant neoplasm of the head, face, and neck who had a feeding tube and depended on staff to eat. The resident’s care plan directed staff to give medications via the peg tube, and physician orders included EBP due to the peg tube and a tracheostomy stoma. During an observation, an LPN administered as-needed oxycodone 5 mg via the resident’s peg tube without applying PPE. The LPN later acknowledged that the resident had been on EBP and that PPE was not applied during the medication administration. The facility’s policy stated that PPE is required for EBP during high-contact care activities, including device care or use of feeding tubes, and the DON stated she expected EBP to be implemented when staff administered medication via a feeding tube.
Failure to Submit Level II PASRR Evaluation for Resident with New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a new mental health diagnosis. The resident, identified as having intact cognition with a Brief Interview for Mental Status (BIMS) score of 13, was diagnosed with bipolar disorder on October 2, 2023. Despite this new diagnosis, the facility did not complete a Level II PASRR evaluation, which is required when a resident has a new or changed mental health condition. The resident's clinical record showed a negative Level I PASRR screening completed on July 31, 2023, which documented depression and altered mental status but did not reflect the new diagnosis of bipolar disorder. The resident's care plan, revised on September 5, 2024, noted behavior problems, including refusal to be checked and changed when wet, seeking out women, and pacing the halls. The care plan aimed to prevent negative outcomes from these behaviors. The resident was also receiving antipsychotic medication, aripiprazole, for bipolar disorder since June 11, 2024. The Director of Nursing (DON) acknowledged the oversight, stating that the facility did not have a policy or protocol for completing PASRRs and followed the regulations, which led to the failure to conduct the necessary Level II PASRR evaluation.
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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 Eldora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hubbard Care Center | 9.9 mi | ★★★★★ | 6 | 0 |
| The Village Of Ackley | 13.8 mi | ★★★★★ | 8 | 0 |
| Scenic Manor | 14 mi | ★★★★★ | 5 | 0 |
| Oakview Nursing Home | 15.6 mi | ★★★★★ | 1 | 0 |
| Zearing Health Care, Llc | 16.4 mi | ★★★★★ | 13 | 1 |
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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.