Inspection Reports for
Eldon Nursing &Amp; Rehab

Complaint numbers 2634421, 2620436, and 2645723 were investigated. The complaints involved failure to properly assess and treat wounds, failure to provide adequate hygiene assistance, and failure to schedule dental appointments. The complaints were substantiated based on observations, interviews, and record reviews.

The facility failed to document assessments and obtain physician orders for new wounds on one resident, failed to provide adequate hygiene care to six residents requiring assistance with showers, and failed to ensure timely dental appointments for one resident with dental pain and broken teeth. Multiple residents were observed with unkempt hair and poor hygiene, and documentation of showers was incomplete or missing.

Complaint #1579387 involved allegations that Resident #2 physically abused Resident #1, resulting in bruising and a black eye. The complaint also included failure to timely report the abuse, failure to investigate properly, and failure to update care plans accordingly.

The facility failed to protect Resident #1 from physical abuse by Resident #2, failed to timely report the abuse allegation to the state agency within two hours, failed to conduct a thorough investigation of the abuse allegation, and failed to update the care plan for Resident #2 to include behavioral issues and interventions.

The complaint investigation was substantiated with findings that the facility failed to complete required elopement assessments and failed to prevent a cognitively impaired resident from eloping by driving the facility van. Immediate Jeopardy was identified on 1/18/25 and removed on 1/22/25 after corrective actions.

The facility failed to complete required elopement assessments for Resident #1, who wanders daily and has exit-seeking behavior. Additionally, the facility failed to provide adequate supervision when the resident eloped by driving the facility van nine miles, with keys left in the vehicle. Immediate Jeopardy was identified but later removed after corrective actions.

The facility failed to monitor and notify physicians of significant weight loss and Registered Dietician recommendations for residents, lacked a dialysis agreement and staff training on dialysis care, improperly stored and labeled medications with expired and loose pills, and did not implement enhanced barrier precautions for residents requiring such infection control measures.

The complaint was substantiated based on interviews and record reviews. Resident #2's family witnessed the incident and reported it immediately. The facility responded by notifying the Director of Nursing, Administrator, physician, and Resident #1's Durable Power of Attorney, and implemented safety measures.

The facility failed to implement interventions to prevent Resident #2, who had a history of similar behaviors, from sexually abusing Resident #1. The incident was reported promptly, and safety measures including 15-minute checks and a safety plan were put in place. Resident #1 was not injured and did not recall the incident.

The complaint investigation found that staff did not notify the resident's physician of high blood glucose readings despite multiple readings over 400 mg/dL from 3/4/24 to 3/23/24. The resident was admitted to the hospital with diabetic ketoacidosis. Interviews with the physician, Director of Nursing, Certified Medication Technician, Licensed Practical Nurse, and administrator confirmed expectations for notification were not met.

The facility staff failed to notify the physician of Resident #1's blood glucose results over 400 mg/dL in a timely manner, resulting in the resident's hospitalization for diabetic ketoacidosis. Multiple high glucose readings were documented without physician notification, contrary to facility expectations and physician instructions.

The visit was complaint-related due to allegations of insufficient staffing leading to residents not receiving timely assistance with bathing and toileting. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to provide sufficient nursing staff according to their Facility Assessment, resulting in failure to assist five residents with showers and one resident with toileting. Observations and interviews confirmed residents experienced delays in care and inadequate assistance due to staffing shortages.

The facility was found deficient in multiple areas including failure to maintain wheelchairs in a clean and safe condition, incomplete employee background checks, failure to complete required screenings and care plans timely, improper wheelchair propulsion, lack of nurse aide training certification, improper food storage practices, and failure to conduct regular bed rail entrapment assessments.

The facility was found deficient in multiple areas including failure to notify residents or representatives in writing about bed hold policies, improper medication storage including expired and loose medications, failure to serve food according to nutritional menus and portion sizes, inadequate kitchen sanitation and food safety practices, and lapses in infection control practices such as improper hand hygiene and failure to monitor residents for COVID-19 symptoms consistently.