Hudson Elms Nursing Center

In the surveyor’s words

From the most serious findings on record at Hudson Elms Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 16, 2025

  Based on review of open and closed medical records, review of hospital records, review of the facility investigation, review of the hazardous chemical policy, review of in-service education, review of Material Safety Data Sheets (MSDS), review of facility self-reported incidents, observations of the housekeeping cart, interviews with staff, interviews with residents, and review of an emergency medical services report, the facility failed to properly store hazardous chemicals when a reasonable risk to resident safety was present. […]

• Actual harm, isolatedF744Feb 22, 2024

  Based on record review, interview, and facility self-reported incident (SRI) review, the facility failed to develop and implement effective, comprehensive, and individualized dementia/behavioral health care plans to address the total care needs of all residents and to prevent a resident-to-resident altercation resulting in resident injury. This affected two residents (#31 and #35) of three residents reviewed for abuse. The facility census was 34. Actual harm occurred on 02/13/24 when Resident #35 sustained a head injury, which included bleeding from the head with two bumps (one to the forehead and one behind the ear) as a result of a resident-to-resident altercation that occurred after he wandered into Resident #31's room. […]

• Actual harm, isolatedF697May 18, 2023

  Based on record review, review of pharmacy delivery sheets, review of facility policy and interviews with family and staff, the facility failed to provide Resident #3 effective pain management, including the administration of narcotic analgesic medication as ordered to prevent unrelieved pain. Actual harm occurred on 05/05/23 when physician ordered narcotic medications for pain including Oxycodone tablets and Fentanyl patches were not available to administer to Resident #3, and Resident #3 rated his pain level a nine on a scale of one to 10 with 10 being the most severe pain. On 05/07/23 at 8:46 P.M. Resident #3 stated he was ready to flip out and complained of pain, anxiety, and restlessness. These pain medications were not available from 05/05/23 through 05/08/23. […]

• Actual harm, isolatedF760Jul 23, 2021

  Based on record review and interview the facility failed to ensure Resident #312, who had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred when nursing staff failed to check and routinely monitor Resident #312's blood sugars and administer insulin (for diabetes) as ordered by the physician from 05/18/21 (admission) through 07/17/21 resulting in episodes of [CONDITION(S)] (very elevated blood sugars) and elevation of her hemoglobin A1c (HbA1c), a laboratory test which revealed the average blood sugar levels for a two to three month period. Resident #312 was noted to have increased pain requiring the use of as needed pain medication as a result of the increased blood sugars. […]

• No harm, potential for more than minimal, widespreadF812May 12, 2026

  Based on observation, interviews and facility policy, the facility failed to ensure the kitchen was maintained in a clean sanitary manner and that food was stored and labeled properly. This had the potential to affect 43 out of 43 residents who ate meals in the facility's kitchen. The facility census was 43.Findings include:1.Interview and observation on 05/04/26 at 9:40 A.M. with Kitchen Director (KD) #875 during kitchen initial tour revealed the following:-A container of Pork and Beans dated 04/28/26. […]