Eldon Nursing & Rehab: Wound Care Documentation Failures - MO
The resident was already receiving daily wound care to multiple sites, including the buttock, coccyx, right outer leg, left inner knee, right inner knee, left lower back, and left hip. A foam dressing on the left heel had been reinforced at some point, but it was undated. Nobody could say when it had been placed.
The Director of Nursing said she assessed the resident's wounds on October 17 and found redness on the right inner knee. She applied skin prep, put a blanket between the resident's knees, and told aides to keep the heels elevated. Then she passed the information along verbally to the next shift's nurse. She did not write a wound assessment. The only documentation was a mark on the TAR, the medication and treatment administration record, which is not a clinical assessment.
Two days passed.
On October 20, hospice RN G arrived and found the resident's left heel dressing soft and spongy. He also learned from RN A, the facility nurse on duty, that a wound on the right inner knee had appeared over the weekend and that no treatment order existed for the left heel. RN G then provided orders to treat both knees.
RN A told inspectors she had not personally assessed the resident's wounds that morning. She said she took the hospice nurse's recommendations and contacted the physician for orders. She acknowledged that when a nurse finds a new wound, the expectation is to document a full assessment, including measurements, color, drainage, and odor, notify the Director of Nursing, and get a physician's order. She did not do those things before hospice arrived.
The Director of Nursing, interviewed twice on October 20, said she would have expected to see a progress note dated October 18 or October 19 describing any new skin concerns and what staff had done. No such notes existed.
The resident's physician said he considered the wounds highly unavoidable given the resident's condition, but said the expectation was clear: if staff found new skin concerns, they should assess and get a treatment order. He had delegated wound management to a mobile wound care provider, but told inspectors that if that provider was unavailable, staff could have called him directly for an order.
Nobody did.
The inspection was triggered by a complaint, filed under complaint number 2634421, and completed November 19, 2025. CMS rated the level of harm as minimal or potential for actual harm, affecting a few residents.
What the record shows is a gap of at least two days during which a hospice resident had an unordered wound on one knee, a deteriorating dressing on a heel, and no written clinical assessment from any facility nurse. The Director of Nursing knew about the knee redness on Friday. The hospice nurse found the problems Monday. In between, the only trace of anyone noticing anything was a verbal handoff at shift change and an entry on a form designed to track whether treatments were given, not whether wounds were worsening.
The resident was on hospice. The wounds, the physician said, were likely unavoidable. But unavoidable and undocumented are not the same thing, and the difference matters when a wound is changing over a weekend and the only person who assessed it told no one in writing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Eldon Nursing & Rehab from 2025-11-19 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 21, 2026 · Our methodology
ELDON NURSING & REHAB in ELDON, MO was cited for violations during a health inspection on November 19, 2025.
A foam dressing on the left heel had been reinforced at some point, but it was undated.
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.