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 found that the facility had an immediate jeopardy (IJ) situation due to inadequate protective oversight of a resident who eloped. The IJ began on 01/18/25 and was removed on 01/22/25 after corrective actions. The violation was substantiated and downgraded to a lower severity level after corrective action.

The facility failed to accurately complete elopement assessments for a resident and did not provide adequate supervision and protective oversight, resulting in the resident eloping from the facility. The facility implemented corrective actions to address these deficiencies.

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 was found deficient in multiple areas including nutrition/hydration status maintenance, dialysis services, medication storage and labeling, and infection prevention and control. Specific failures included inadequate monitoring and notification of significant weight loss, lack of agreements and communication with dialysis providers, unsafe medication storage, and failure to implement enhanced barrier precautions for infection control.

The facility failed to maintain delayed egress locking systems, did not inspect and test the fire alarm system semi-annually, failed to maintain sprinkler systems properly, and did not conduct fire drills as required. Additionally, electrical equipment and surge protectors were not maintained according to code, and night lights were not functional in resident rooms and adjacent toilet rooms.

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, record reviews, and observations confirming the abuse incident between Resident #1 and Resident #2.

The facility failed to ensure residents were free from abuse, neglect, and exploitation as evidenced by an incident where Resident #2 put his/her hand down Resident #1's pants without consent. The facility's investigation and documentation confirmed the incident and subsequent safety measures were implemented.

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 facility failed to notify the physician in a timely manner about a resident's elevated blood glucose levels, resulting in the resident's hospitalization for diabetic ketoacidosis. The facility also lacked a policy directing staff when to notify physicians of changes in resident conditions.

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 facility failed to provide sufficient nursing staff to assist residents with showering and toileting, resulting in delayed care and unmet resident needs. Staff interviews and observations confirmed understaffing and inadequate response to resident call lights.

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 maintenance of a safe and homelike environment, abuse and neglect policies, preadmission screening for mental disorders, baseline care planning, food safety, bed rail safety, and nurse aide training. Several residents were affected by these deficiencies.

The facility failed to provide emergency preparedness training to all staff annually and failed to maintain doors equipped with delayed-egress and access-controlled magnetic locking systems in accordance with NFPA 101. Additionally, the facility did not maintain sprinkler system inspections and testing documentation, failed to conduct required fire drills quarterly, and did not properly secure oxygen storage areas. Several deficiencies related to fire safety and emergency preparedness were cited.

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 several areas including bed hold policy notification, medication labeling and storage, menu and nutritional adequacy, food procurement and sanitation, infection prevention and control, and documentation of resident care and progress notes.

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.

The facility failed to prevent misappropriation of resident funds totaling at least $52,460.88 involving three residents. Investigations revealed unauthorized charges on resident accounts and inadequate security of resident banking information.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.

The facility was found deficient in maintaining a safe, clean, and homelike environment due to persistent urine odors and inadequate housekeeping. Deficiencies were also noted in personal hygiene care for dependent residents, supervision to prevent accidents, and sufficient nursing staff to meet resident needs.

The facility failed to maintain smoke barrier walls free of openings, provide self-closing metal containers for designated smoking areas, and maintain essential electrical systems including annual inspections of main and circuit breakers. Additionally, the facility failed to maintain water temperatures within the required range in resident rooms.

The facility failed to adequately monitor staff during resident transfers, resulting in a resident fall and fracture. Staff did not use required gait belts or proper footwear during transfers, contributing to the injury.

The facility was found deficient in multiple areas including residents' right to private communication, accuracy of assessments, care plan timing and revision, and infection prevention and control. Deficiencies were documented with specific examples and regulatory citations.

The facility failed to provide complete and verifiable documentation of the dry pipe sprinkler system testing and maintenance, and failed to assess electrical receptacles at resident bed locations for physical integrity and grounding. Additionally, the facility did not provide night-lights in several resident rooms, toilet rooms, and shower rooms.

The complaint investigation substantiated that Resident #2 physically abused Resident #1 by hitting him on the back of the head. The facility's failure to prevent and address this abuse was documented.

The facility failed to ensure residents were free from physical abuse as Resident #2 hit Resident #1 on the back of the head. Staff did not adequately address Resident #2's aggressive behaviors or implement effective interventions to prevent harm.