El Dorado Care: Failed Bed Hold Notifications - KS
The December incident involved a resident with end-stage kidney disease, diabetes, and major depression who required substantial help with daily activities and used a wheelchair. Federal inspectors found the facility violated basic notification requirements during what became a week-long hospitalization.
On December 9, 2025, lab results showed the resident's hemoglobin had dropped to 6.1 grams per deciliter. Normal levels for men range from 13.5 to 17.5. Hemoglobin carries oxygen from the lungs to cells throughout the body.
The lab called the facility at 1:13 PM to report the critical results. Just over an hour later, at 2:15 PM, the resident's provider called and ordered immediate transfer to the emergency room. By 2:40 PM, the resident left via ambulance stretcher.
The resident returned to the facility on December 16 after treatment for end-stage kidney disease and anemia. He had a dialysis port surgically placed in his left upper chest during the hospitalization.
But the facility never provided written notification about bed hold policies during the transfer, despite having a policy requiring such notices. The facility also failed to notify the State Long Term Care Ombudsman about the discharge, as required by regulations.
When inspectors requested documentation of the bed hold notice on April 8, 2026, Social Service staff confirmed no notice had been provided. The facility also could not produce evidence that the ombudsman had been notified of the resident's hospital transfer.
The resident's medical records showed he received dialysis treatments and oxygen therapy. His care plan documented that staff should monitor lab results, electrolytes, and kidney function, reporting changes to physicians. Staff were also instructed to watch for mental status changes, lethargy, fatigue, tremors, seizures, and breathing difficulties.
Despite his multiple serious conditions, the resident maintained intact cognition with a score of 15 on mental status testing. His care plan noted he was unable to walk, had poor balance, and required setup assistance to operate his wheelchair. He was classified as a fall risk.
The facility's bed hold policy, dated May 2026, states that staff must inform residents upon admission and before transfers for hospitalization about bed hold policies, unless the transfer is an emergency. For emergency transfers, the facility must provide bed hold information "per state law as applicable." A copy should be filed in the resident's medical record.
The policy specifies that business office representatives should provide bed hold information when residents are transferred for non-emergency hospitalization or therapeutic leave.
When inspectors asked for the facility's ombudsman notification policy, staff could not provide one.
The resident's case highlighted gaps in the facility's transfer procedures. His medical record documented chronic kidney disease Stage 3, indicating moderate to severe loss of kidney function. His diagnoses also included anemia, diabetes, high blood pressure, and major depressive disorder.
The Activities of Daily Living assessment from July 2025 noted the resident required substantial assistance with tasks involving the lower body and could not walk independently. His care plan from December emphasized the need to monitor his kidney function and report laboratory results to physicians.
The critical hemoglobin level that triggered his hospitalization represented a severe drop in the blood's ability to transport oxygen. The resident's return with a new dialysis port indicated his kidney disease had progressed to require more intensive treatment.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, affecting few residents. The facility's failure to maintain proper documentation and notification procedures occurred despite having written policies requiring both bed hold notices and communication with the state ombudsman during resident transfers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for El Dorado Care and Rehab from 2026-04-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
EL DORADO CARE AND REHAB in EL DORADO, KS was cited for violations during a health inspection on April 9, 2026.
Federal inspectors found the facility violated basic notification requirements during what became a week-long hospitalization.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at EL DORADO CARE AND REHAB?
- Federal inspectors found the facility violated basic notification requirements during what became a week-long hospitalization.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in EL DORADO, KS, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from EL DORADO CARE AND REHAB or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 175324.
- Has this facility had violations before?
- To check EL DORADO CARE AND REHAB's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.