Eldon Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Eldon Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 23, 2025

  Based 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. […]

• Actual harm, isolatedF600Jul 2, 2025

  Based 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. […]

• Actual harm, isolatedF600May 20, 2024

  Based 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. […]

• Actual harm, isolatedF580Mar 29, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Feb 26, 2026

  Based 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. […]