El Dorado Care: Resident Dignity Violations - KS
Federal inspectors cited El Dorado Care and Rehab after documenting three separate incidents where Resident 36's ill-fitting clothing compromised his dignity in front of other residents and staff.
The problems started during lunch on April 6. Resident 36 stood up from his dining table when his pants fell below his abdomen, exposing the top of his buttocks. He grabbed his waistband to hold them up while walking. An elderly female resident sitting nearby told inspectors, "I just saw that man's butt."
The next day, inspectors observed the same resident at the nurse's station making a phone call. His plaid pajama pants had slipped below his abdomen again, exposing approximately a quarter of his buttocks. As he walked to the dining room afterward, he kept pulling up his pants to keep them from falling.
Staff noticed but took no immediate action.
Licensed Nurse I told inspectors on April 8 that Resident 36 had not experienced weight loss, so she didn't understand why his clothes weren't fitting properly. She said she would investigate the situation.
Hours later, Administrative Nurse E acknowledged the dignity violation. She explained that Resident 36 had money he needed to spend down and that staff had already planned to buy him new clothes. She admitted it was "a dignity issue" and said she "felt bad the other residents were in the dining room to see it."
The facility's own policy requires staff to treat residents with respect and dignity. The policy, dated June 2025, states that staff must provide person-centered care emphasizing residents' comfort, independence, and personal needs. It specifically requires accommodating residents' use of personal possessions, including clothing, unless doing so would infringe on other residents' rights or safety.
But for at least three days, staff allowed Resident 36's clothing problems to continue while other residents witnessed his repeated exposure.
The inspection revealed a pattern of staff awareness without action. Multiple employees observed the incidents. The licensed nurse acknowledged not understanding why the clothes didn't fit. The administrative nurse confirmed they had plans to address the problem but hadn't acted on them.
Federal inspectors found the facility failed to promote dignity for Resident 36. The violation falls under regulations requiring nursing homes to ensure residents can maintain their dignity and be free from humiliation.
The case highlights how seemingly minor clothing issues can become significant dignity violations when left unaddressed. Resident 36's repeated exposure occurred in common areas where other residents gathered for meals and activities.
Staff had identified a solution - purchasing properly fitting clothes with the resident's own money that needed to be spent down. But they failed to act quickly enough to prevent multiple incidents of public exposure.
The administrative nurse's comment about feeling bad that other residents witnessed the exposure underscores the impact on both Resident 36 and those around him. The female resident's direct observation - "I just saw that man's butt" - demonstrates how the clothing failures affected the entire dining room environment.
Federal regulations require nursing homes to accommodate residents' personal possessions, including clothing, to maintain their dignity and comfort. When clothing doesn't fit properly, facilities must address the problem promptly to prevent embarrassment and maintain residents' sense of self-respect.
The inspection found minimal harm but noted the potential for actual harm to the resident's dignity and well-being. The facility's failure to act despite having both the means and the plan to solve the problem led to unnecessary humiliation for Resident 36 in front of his peers.
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.
The problems started during lunch on April 6.
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?
- The problems started during lunch on April 6.
- 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.