Eldon Nursing & Rehab

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal and/or wound care, when staff failed to perform appropriate hand hygiene, and glove changes for three residents (Resident #1, #6, and #34 ), of five sampled residents, Facility staff failed to ensure sanitary conditions for catheter tubing when they failed to keep the tubing off the floor for three residents (Resident #2, #48, and #54) out of three sampled residents. Facility staff failed to post Enhanced Barrier Precautions (EBP) signs for five residents (Resident #2, #23, #31, #48, and #54) out of five sampled residents. The facility census was 53.1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 53.1. Review of the facility's policy titled, Antibiotic Stewardship Program (ASP), undated, showed it directed staff as follows: -Infection Preventionist (IP): This person will be the hub of the ASP. They will have the knowledge and expertise to effectively develop, implement, and monitor the ASP; -The IP/designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription; -The IP/designee will be responsible for auditing of the completeness of antibiotic prescribing documentation to include dose, route, state date, end date, days of therapy, and indication; -The IP/designee will track C. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide appropriate care to meet basic hygiene needs for three dependent residents (Resident #8, #34 and #35), to include appropriate incontinent care, out of sampled residents. The facility census was 53.1. Review of the facility's policies showed staff did not provide a policy that addressed toileting/ incontinent care of dependent residents. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 12/12/25, showed staff assessed the resident as follows: -Moderately impaired cognition; -Required mobility device - wheelchair; -Required substantial/maximal assistance with toilet transfer. toilet hygiene, both upper and lower body dressing and with putting on/taking off footwear; -Frequently incontinent of urine. [...]

Inspectors wroteBased on interview and record review, facility staff failed to meet professional standards when staff failed to obtain proper Against Medical Advice (AMA) documentation for one resident (Resident #60) of one sampled discharge close record. The facility census was 53.1. Review of the facility's Leaving the Facility against Medical Advice policy (AMA) Release, undated, showed staff are directed when a resident or resident's legal representative expresses the desire to leave the facility before the attending physician has discharged the resident staff will: --Notify the physician; --Notify the administrator; --Notify the Director of Nursing (DON); -Document completion of leaving Facility Against Medical Advice release form; -Present form to resident or legal representative regardless of whether it is believed it is the resident or legal representative will sign it. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure a medication error rate of less than five percent (%). Out of 34 opportunities observed, three errors occurred, resulting in a 9.68% error rate, which affected one resident (Resident #24) of eleven sampled residents. The facility census was 53. 1. Review of the facility's Medication Errors and Drug Reactions policy, undated, showed staff are directed to report all medication errors immediately to the physician, Director of Nursing (DON) and administrator. The policy did not contain a definition of a medication error. Review of the facility's Medication Administration Guidelines policy, undated, showed the physician's order must be verified before the medication is administered. The policy did not contain a definition of a medication error. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care for three residents (Resident #1, #2, and #23) out of 14 sampled residents. The facility census was 53.1. Review of the facility's Care Plan Comprehensive, undated, showed the assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition. The interdisciplinary care plan team is responsible for the periodic review and updating the care plans as follows: -When a significant change in the resident's condition has occurred; -At least quarterly; -When changes occur that impact the residents' care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to update the Facility Assessment at least annually, failure to review the assessment within 12 months may result in the facility failing to identify a factor that would require a change to the assessment. The facility census was 53.1. Review of the Facility's Assessment, dated 12/04/24, showed the assessment did not contain documentation the assessment was reviewed for 2025 During an interview on 02/26/26 at 1:37 P.M., the administrator said she does not know why the facility assessment has not been reviewed and updated since 2024. The administrator said she is aware the assessment needs to be completed at least annually. During an interview on 03/04/26 at 9:50 A.M., the Director of Nursing (DON) said he/she was not aware the facility assessment had not been updated since 2024. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide care to meet the basic hygiene needs for six residents (Resident #1, #2, #3, #4, #5, and #6) out of six sampled residents who required assistance with showers. The facility census was 62. 1. Review of policies provided by facility staff showed the policies did not contain a shower policy. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/14/25, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required substantial to maximal assistance from staff for personal hygiene;-Dependent on staff for showers. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to meet professional standards of care when staff failed to document an assessment of new wounds and obtain treatment orders from the physician for one resident (Resident #7) out of two sampled residents with pre-existing wounds. The facility census was 62.1. Review of the facility's Pressure Ulcer Care and Prevention policy, undated, showed the purpose is to prevent and treat further breakdown of pressure ulcers, and the nurse is responsible to provide the treatment as ordered by the attending physician and to implement measures for pressure ulcer prevention. Review of the facility's Wound Care and Treatment policy, undated, showed the purpose is to prevent and treat all wounds, and there must be a specific order for the treatment. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure one resident (Resident #1) out of three sampled residents received timely assistance to schedule an appointment with a dentist, after the resident reported he/she had broken teeth and an intermittent toothache. The facility's census was 62.1. Review of the facilities policies showed facility staff did not provide a policy for dental care and services.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 10/14/25, showed staff assessed the resident as moderate cognitive impairment, with mouth or facial pain, and discomfort or difficulty with chewing. Review of the resident's care plan, revised 10/08/25, showed staff assessed the resident has his/her own teeth, with missing or broken teeth, and required staff assistance for oral care as needed. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when Resident #2 with a history of physical aggression punched Resident #1 in the face which resulted in bruising to his/her eye. The facility census was 65. Review of the facility's abuse and neglect policy, undated, showed staff are directed that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection.1. [...]

Inspectors wroteBased on interview, and record review, the facility staff failed to report an allegation of abuse for one resident (Resident #1) out of four sampled residents within in two hours to the administrator and the Department of Health and Senior Services (DHSS). The facility census was 65.1. Review of the facility's Abuse and Neglect policy, undated, showed all allegations of abuse will be reported no later than two hours to the State Survey Agency and if applicable law enforcement.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 04/04/25, showed staff assessed the resident with severe cognitive impairment. Review of the resident's nurse's notes, 06/26/25 at 6:07 A.M., showed staff documented Resident #1 with a black eye and bruising to his/her shoulders. [...]

Inspectors wroteBased on interviews and record reviews, facility staff failed to initiate and complete a thorough investigation of alleged resident to resident abuse for one resident (Resident #1). The facility census was 65.1. Review of the facility's Abuse and Neglect policy, undated, showed when an incident of abuse is reported the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: Who was involved; Resident's statements; Resident roommates' statements; Interviews obtained from 3-4 three to four residents; Involved staff and witness statements of events; A description of the resident's behavior and environment at the time of the incident; Injuries present including a resident assessment; Observation of resident and staff behaviors during the investigation and environmental considerations. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to update the plan of care with changes in the resident's behaviors and measurable interventions for one resident (Resident #2) out of four sampled residents. The facility census was 65.1. Review of the facility's Comprehensive Care Plan policy, dated March 2015, showed an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment tool. Assessment of each resident is an ongoing process, and the care plan will be revised as changes occur in the resident's condition. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide protective oversight for one cognitively impaired resident (Resident #1) with a history of elopement, when facility staff left the transport van keys in the vehicle and the resident with a history of exit seeking, wandering and elopement attempts eloped from the facility, got into the facility van, and drove nine miles. Facility staff were not aware the resident was missing. The facility census was 63. The administrator was notified on 1/22/25 at 3:17 P.M., of an Immediate Jeopardy (IJ) which began on 1/18/25. The IJ was removed on 1/22/25, as confirmed by surveyor onsite verification. Review of the Facility's Elopement Policy, undated, showed staff are directed as follows: -Determine when resident was last seen and by whom, description of their clothing, and where last seen; [...]

Inspectors wroteBased on interview and record review, facility staff failed to accurately complete elopement assessments for one resident (Resident #1), who staff identified as a resident who wanders daily. The facility census was 63. Review showed the Facility's Elopement Policy, undated, did not direct staff on how to complete an elopement assessment. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool used to assess resident, dated 10/08/24, showed staff assessed the resident as follows: -Cognitively impaired; -Suffers from delirium (a temporary state of mental confusion and disorientation that can cause significant changes in behavior, thinking, and perception); -Wanders daily; -Inattention and disorganized thinking that comes and goes. [...]

Inspectors wroteBased on observation, interviews, and record review, facility staff failed to safely store and label medication in one out of two medication storage rooms, and two out of three medication storage carts. The facility census was 63. 1. Review of the facility's Medication, Storage of policy, dated March, 2015, showed no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines. Drugs must be stored in an orderly manner in cabinets, drawers, or carts. 2. Observation on 07/23/24 at 2:22 P.M., showed the 300/400 hall medication storage room contained: -Four intravenous caps with an expiration date of 06/26/24; -One 30 Oz. bottle of Liquid Protein with an expiration date of 01/19/24. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement the enhanced barrier precautions (EBP) policy developed and educated on at the facility when facility staff failed to post signage or other system to alert staff of resident's who required EBP and place appropriate personal protective equipment (PPE) in close proximity for two (Resident #13 and #52) of two sampled residents with wounds and one (Resident #60) of one sampled resident with an indwelling gastrostomy tube ((g-tube) surgically placed tube that inters the stomach to deliver fluids and nutrition, that required EBP). The facility census was 63. 1. Review of the facility's EBP to infection Control Guidance policy dated March 2024 showed: [...]

Inspectors wroteBased on interview, and record review, facility staff failed to monitor weights, notify the physician of the Registered Dietician's (RD) recommendations and of the resident's significant weight loss of 8.97% in three months and 12.68 % in six months for one resident (Resident #21) out of three sampled residents. The facility failed to monitor weights and notify the physician of the RD's recommendations for one resident (Resident #61) out of three sampled residents. The facility census was 63. 1. Review of the facility's Diet Orders policy, undated, showed the policy did not address recommendations of the RD nor monitoring of residents' weight loss. Review of the facility's policies showed staff did not provide a policy for weight loss, or RD recommendations. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to obtain and maintain an agreement and ongoing communication with the dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) facility for one of one resident who received dialysis services at a dialysis facility and provide staff training on dialysis and/or renal disease. The census was 63. 1. Review of the facility's dialysis policy, dated March 2015, showed communication between the facility and dialysis unit as follows: -The Dialysis Communication record will be sent with the resident on each dialysis visit; -All care concerns in the last 24 hours will be addressed, including the last medications given and facility contact person; [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement interventions for one resident (Resident #2), with a history of similar behaviors, which failed to ensure one resident (Resident #1) remained free from sexual abuse, when Resident #2 put his/her hand down Resident #1's pants without Resident #1's consent. The facility census was 65. 1. Review of the facility's abuse and neglect policy, undated, showed it is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify one resident's (Resident #1's) out of three sampled residents physician of the resident's blood glucose (the main sugar found in your blood) results over 400 milligrams (mg) per deciliter (dL) results in a timely manner which resulted in the resident being admitted to the local hospital for diabetic ketoacidosis (a complication of diabetes in which acids build up in the blood to levels that can be life-threatening). The census was 57. 1. Review of the facility's policies showed the facility did not have a policy to direct staff on when to notify the physician for changes in resident conditions. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/01/24, showed staff assessed the resident as follows: -Severely cognitively impaired; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide staff in accordance with their Facility Assessment based on the care needs of their residents. Facility staff failed to assist five residents (Resident #1, #2, #3, #4, and #5) with showers, and assist one resident (Resident #1) with toileting. The facility census was 70. 1. Review of the Facility Assessment, dated 11/22/22, showed facility staff documented the staffing requirements needed on a 24 hour basis to meet the needs of their residents for an average census of 55-65 are as follows: -Registered Nurse (RN): 1; -Licensed Practical Nurses (LPN): 4-8; (minimum 1 LPN/RN charge nurse per shift); -Certified Nursing Assistant (CNA): 20-25; (1-10 on day shift, 1:15 on evening shift, and 1:20 on night shift); -Addition to nursing staff needed for behavioral healthcare: 1-3. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. The facility census was 57. 1. Review of the facility's Basics for Handling Food Safely policy, dated August 2013, showed the policy directed staff to: -not cross-contaminate; -refrigerate perishable food within two hours or within one hour when the temperature is above 90 degrees Fahrenheit; -wrap perishable food, such as meat and poultry, securely to maintain quality and to prevent meat juices from getting onto other food; -place leftover food into shallow containers and immediately put in the refrigerator or freezer for rapid cooling; -use cooked leftovers within four days. Review showed the policy did not direct staff to label or date food items when opened to maintain the products identity and timeline for use. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for three residents (Resident #47, #38 & #5) when staff failed to clean and maintain wheelchairs. The facility census was 57. Review of policies provided by the facility showed no policy on the cleaning and maintenance of the resident's wheelchairs. 1. Observation on 05/30/23 at 11:43 A.M., showed Resident #47 sat in his/her wheelchair in the dining room. Further observation showed the resident's wheelchair had white drops splattered on the wheels and dried food debris on the seat and back of the chair. Additional observation showed the vinyl on the left armrest cracked, while the the front of the right armrest, had no vinyl on it. 2. Observation on 05/31/23 at 8:14 A.M. [...]

Inspectors wroteBased on interview and record review, facility staff failed to check the Employee Disqualification List (EDL) (a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident) or the Certified Nurse Aide (CNA) Registry in accordance with their facility policy for eight out of nine sampled staff. The facility census was 57. 1. Review of the facility's policy titled, Abuse Prohibition Protocol Manual, dated August 2017, showed staff were directed to do the following: -It is the policy of the facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check (CBC); [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for five residents (Resident #2, #5, #30, #47, and #56). The facility census was 57. 1. Review of the facility's policy titled, Care Planning/Interdisciplinary Team, undated, showed staff were directed to develop an individualized comprehensive care plan for each resident. Review of the facility's policy titled, Care Plan Comprehensive, undated, showed staff were directed to do the following: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to propel three residents (Residents #31, #47, and #62) in wheelchairs in a manner to prevent accidents. The facility census was 57. 1. Review of policies provided by the facility showed no policy on how staff are to properly propel residents in wheelchairs. 2. Review of Resident #31's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/12/23, showed staff assessed the resident as: -Severe cognitive impairment; -Used a wheelchair for mobility. Observation on 05/30/23 at 3:47 P.M., showed an unknown staff member propelled the resident down the 400 hall to the dining room table in a wheelchair without the use of foot pedals. 3. Review of Resident #47's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive Impairment; -Uses a wheelchair for mobility. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure eleven Nurse Aides (NAs) (NA V, NA X, NA T, NA P, NA W, NA B, NA U, NA R, NA J, NA Q, & NA S) completed the nurse aide training program within four months of their employment in the facility. The facility census was 57. 1. Review of the policies provided by the facility showed no policy for Nurse Aide training and requirements. 2. Review of NA V's personnel file showed a hire date of 06/30/20. Further review showed the file did not contain documentation the NA completed a nurse aide training program. 3. Review of NA X's personnel file showed a hire date of 11/16/21. Further review showed the file did not contain documentation the NA completed a nurse aide training program. 4. Review of NA T's personnel file showed a hire date of 06/28/22. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to conduct inspections of bed rails as part of a regular maintenance program for three residents (Resident #30, #55 and #56) to identify areas of possible entrapment. The facility census was 57. 1. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated March 10, 2006, showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013 identifies seven different potential, zones of entrapment. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #31) with a mental disorder had a Level I Pre-admission Screening (used to evaluate for the presence of psychiatric conditions to determine if a Pre-admission Screening and Resident Review (PASARR) level II screen is required) as required. The facility census was 57. Review of policies provided by the facility showed no PASARR policy. 1. Review of Resident #31's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/10/22, showed the following: -admitted on [DATE]; -Unit is Medicare and/or Medicaid Certified; -Evaluated by Level II PASARR and determined to have a serious mental illness and/or mental retardation or a related condition; -Serious Mental Illness; -Entered from Psychiatric hospital; -Cognitively Impaired; [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for two residents (Resident #11 and #15). The facility census was 57. 1. Review of the facility's policy titled, Care Plan, Temporary, undated, showed staff were directed to do the following: -A temporary care plan will be implemented to meet the new resident's immediate needs; -To assure that the resident's immediate care needs are met and maintained, a temporary care plan will be implemented for the resident within twenty-four hours of admission; -The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed according to the Resident Assessment Instrument (RAI) process. [...]