Hudson Memorial Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, patternF689Oct 12, 2022

  Based on observation, interview, and record review, the facility failed to ensure two staff were present during van transportation, staff correctly secured residents into the van during transportation and failed to notify the licensed nurse or supervisor in a timely manner prior to transferring/transporting the residents after the facility van had to make an emergency stop when a car ran a stop sign resulting in 2 (Residents #1 and #2) residents being thrown forward out of their wheelchairs. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who required assistance of two people for transfers and sustained fractures to bilateral lower extremities. […]

• No harm, potential for more than minimal, widespreadF838Dec 19, 2024

  Based on document review and interviews, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents. This deficient practice had the potential to affect all residents of the facility. The total census was 60 residents. The findings are: A review of the Facility Assessment Tool, dated 07/11/2024, indicated the assessment was reviewed with the Quality Assessment and Assurance and Quality Assurance and Performance Improvement (QAA/QAPI) committee on 07/12/2024. […]

• No harm, potential for more than minimal, patternF812Jul 15, 2026

  Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure foods were stored and prepared under sanitary conditions for residents who received foods from one of one kitchen. The findings include: During the initial tour on 07/12/2025 at 9:55 AM, with Dietary Aide (DA) #1, this surveyor observed a box of opened egg rolls, stored in the walk-in freezer, in a plastic bag open and unsealed. DA #1 indicated that the bag should have been sealed. During an observation and concurrent interview on 07/14/2026 at 10:20 AM, there was a quarter pan found under the food prep-area, identified by the Dietary Supervisor (DS) as ready for use. It was wet and nested inside other quarter pans. […]

• No harm, potential for more than minimal, patternF759Dec 19, 2024

  Based on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%) during the medication administration observation of 3 (Residents #11, #18, and #25) of 6 (Residents #11, #18, #20, #25, #35, and #54) sampled residents who received medications from 2 Licensed Practical Nurses (LPNs). 26 opportunities of medication administration were observed and 3 of the 26 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 11.54%. The findings are: On 12/28/2024, LPN #4 was observed as she conducted the 8:00 AM medication pass to residents. […]

• No harm, potential for more than minimal, patternF761Dec 19, 2024

  Based on observations, interviews, record review, and facility policy review, the facility failed to ensure medication and/or biologics were properly stored for 2 (Resident #37 and Resident #40) sampled residents. The findings include: 1. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/2024 revealed Resident #40 had a Brief Interview of Mental Status (BIMS) of 14 indicating cognitively intact. a. A plan of care for Resident #40 (revision date 9/18/2024) revealed Resident #40 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. b. On 12/16/24 at 2:40 PM, this surveyor observed Resident #40 lying in bed. […]