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Complaint Investigation

Eldon Nursing & Rehab

November 19, 2025 · Eldon, MO · 1001 East North Street
Citations 3
CMS Rating 2/5
Beds 90
Provider ID 265555
Healthcare Facility
Eldon Nursing & Rehab
Eldon, MO  ·  View full profile →
Inspection Summary

ELDON NURSING & REHAB in ELDON, MO — inspection on November 19, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0658
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

During an interview on 10/20/25 at 12:48 P.M., hospice RN G said RN A reported to him/her the wound to the resident's right inner knee must have appeared over the weekend, and there wasn't a treatment order for the left heel.

Hospice RN G said he/she received orders from RN A to treat the resident's right and left inner knees.

During an interview on 10/20/25 at 1:18 P.M., the Director of Nursing (DON) said he/she assessed the resident's wounds on 10/17/25, and there was redness to the resident's right inner knee.

The DON said he/she applied skin prep, placed a blanket between the resident's knees and directed the aides to float the resident's heels. He/She said he/she passed on the information in report to the oncoming nurse, but did not document an assessment of the resident's skin other than on the TAR.

During an interview on 10/20/25 at 4:21 P.M., RN A said a facility nurse in collaboration with the hospice nurse completes the treatments to the resident's wounds daily and documents on the TAR. RN A said if the nurse identifies a new wound/skin concern, the nurse is expected to document an assessment (measurement, color, drainage, odor), notify the DON, and obtain orders from the physician. RN A said he/she did not personally assess the resident's wounds earlier in the day, but he/she took the recommendations from hospice RN G and contacted the physician for orders.

During an interview on 10/20/25 at 3:55 P.M., the DON said he/she would expect the nurses to complete a skin assessment on the resident daily with scheduled wound care and document any new skin concerns.

The DON said he/she would expect to see a progress note dated 10/18 or 10/19 regarding any new skin concerns and what staff did about it.

During an interview on 10/22/25 at 12:32 P.M., the resident's physician said he/she considered the resident's wounds highly unavoidable but would expect if staff identified new skin concerns/wounds, staff would assess the resident and obtain a treatment.

The physician said he/she had deferred the resident's wound management to a mobile wound care provider, but if the wound care provider was not available to give an order for treatment, staff could have contacted him/her for an order.Complaint# 2634421

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Eldon Nursing & Rehab

1001 East North Street Eldon, MO 65026

SUMMARY STATEMENT OF DEFICIENCIES

Observation on 10/20/25 at 9:38 A.M., showed the resident went up and down the hallways in his/her wheelchair with greasy, unkempt hair, food debris on his/her shirt, and dark brown stains on his/her pants. 8.

During an interview on 10/20/25 at 4:04 P.M., Certified Nurse Aide (CNA) C said he/she is the shower aide and works 12-hour shifts. CNA C said he/she assists residents with showers from 7:00 A.M. to 3:00 P.M., and works the floor from 3:00 P.M. to 7:00 P.M.

CNA C said he/she tries to do as many showers as he/she can during the day but sometimes he/she can't get all the showers completed. CNA C said staff should document showers in the Electronic Medical Record (EMR) but if it gets too busy, he/she doesn't do it. He/She said if a resident refuses a shower, he/she should tell the charge nurse or Director of Nursing (DON) and that should also be documented in the EMR. He/She said the residents who require two staff to assist are hard to get done, because they take more time and there aren't always two staff available to assist.

During an interview 10/20/25 on at 4:28 P.M., Registered Nurse (RN) A said staff are expected to offer residents two showers per week, the CNAs are expected to tell the nurse if a resident refuses a shower, and the nurse would try to get the resident to shower.

During an interview on 10/20/25 at 1:50 P.M., the DON said staff are expected to offer residents a shower two times per week, and he/she expects each resident to be assisted with at least one shower per week.

The DON said if a resident refuses his/her shower, staff should first try to re-approach, have the resident sign refusal on paper, tell the nurse, document the refusal in the computer, and the nurse should complete a progress note. He/She said if staff did not document the resident refused his/her shower, it is likely staff did not offer or assist the resident with a shower/bath.

During an interview on 10/20/25 at 4:45 P.M., the Administrator said the residents get showers at least once a week, but the expectation is two times a week, and staff are expected to document showers in the residents' medical record.

The administrator said he/she has not reviewed the shower documentation in the EMR recently, but he/she visually monitors residents and directs staff to assist residents with hygiene needs.

Complaint # 2620436,

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Eldon Nursing & Rehab

1001 East North Street Eldon, MO 65026

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited ELDON NURSING & REHAB in ELDON, MO for a deficiency under regulatory tag F-F0791 during a complaint investigation conducted on 2025-11-19.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide or obtain dental services for each resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of ELDON NURSING & REHAB.

Correction Status: Deficient, Provider has no plan of correction.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ELDON, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ELDON NURSING & REHAB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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