Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
44% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error where a resident (Resident #1) consumed medications not prescribed to them after drinking crushed medications placed in liquid supplements intended for other residents.
Complaint Details
The complaint investigation found that Resident #1 consumed medications not prescribed to them due to lack of supervision during medication administration. The nurse responsible was disciplined with a written warning and retrained. The Advanced Practice Registered Nurse (APRN) was notified and monitored the resident with no adverse effects reported. The complaint was substantiated.
Findings
The facility failed to ensure adequate supervision during medication administration, resulting in Resident #1 consuming unprescribed medications. The nurse responsible was given a written warning and retrained on medication administration protocols. The resident was monitored and no adverse reactions were reported.
Deficiencies (1)
Failure to ensure residents were supervised when receiving medications that were crushed and placed in liquid supplements, resulting in one resident consuming unprescribed medications.
Report Facts
Residents reviewed: 5
Assessment Reference Date: Aug 14, 2025
Medication error incident date: Oct 23, 2025
Written warning date: Oct 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Nurse responsible for medication error, given written warning and retraining |
| RN Supervisor | Registered Nurse Supervisor | Evaluated resident after incident and reported to Director of Nursing |
| LPN #2 | Licensed Practical Nurse | Monitored Resident #1 after incident during evening shift |
| CNA #3 | Certified Nursing Assistant | Observed Resident #1 drinking another resident's supplement and reported incident |
| CNA #4 | Certified Nursing Assistant | Observed Resident #1 drinking unknown supplement and reported medication crumbles |
| DON | Director of Nursing | Instructed nurse involved and oversaw corrective actions |
| APRN | Advanced Practice Registered Nurse | Notified of incident, assessed resident for allergies and monitored condition |
| Administrator | Facility Administrator | Informed of incident and nurse disciplinary actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error where Resident #1 consumed medications that were not prescribed to them by drinking crushed medications placed in liquid supplements intended for other residents.
Complaint Details
The complaint investigation found that Resident #1 consumed two liquid supplements containing crushed medications prescribed to other residents. The nurse responsible was given a written warning and retrained. The Advanced Practice Registered Nurse (APRN) was notified and monitored the resident with no adverse reactions. The incident was substantiated as a medication error due to lack of supervision.
Findings
The facility failed to ensure adequate supervision during medication administration, resulting in Resident #1 consuming unprescribed medications. The nurse responsible was found to have left supplements unattended, leading to the medication error. The resident was monitored with no adverse effects reported, and the nurse received a written warning and retraining on medication administration protocols.
Deficiencies (1)
Failed to ensure residents were supervised when receiving medications that were crushed and placed in liquid supplements, resulting in one resident consuming unprescribed medications.
Report Facts
Residents reviewed: 5
Medication error incident date: Oct 23, 2025
Written warning date: Oct 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Nurse responsible for the medication error and received written warning and retraining |
| RN Supervisor | Registered Nurse Supervisor | Reported the medication error and evaluated the resident |
| APRN | Advanced Practice Registered Nurse | Contacted after the incident to assess the resident and ordered monitoring |
| DON | Director of Nursing | Informed of the incident, instructed nurse involved, and confirmed corrective actions |
| CNA #3 | Certified Nursing Assistant | Observed Resident #1 drinking the wrong supplement and reported the incident |
| CNA #4 | Certified Nursing Assistant | Observed Resident #1 drinking the supplement and reported medication crumbles |
Inspection Report
Routine
Census: 60
Deficiencies: 8
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident funds, pre-admission screening, resident activities, medication administration, medication storage, food safety, facility-wide assessment, and infection control at Hudson Memorial Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to convey resident funds timely, lack of Level II PASRR evaluation for a resident, inconsistent provision of individual activities, medication errors exceeding 5%, improper medication storage accessible to residents, unsanitary food preparation conditions, incomplete facility-wide assessment, and failure to apply proper PPE during care of a resident on enhanced barrier precautions.
Deficiencies (8)
Failed to convey a resident's personal funds within 30 days after death.
Failed to coordinate with state agency to obtain Level II PASRR evaluation for a resident.
Failed to provide individual activities consistently for a cognitively impaired resident.
Medication error rate of 11.54% observed during medication administration.
Medications and biologics improperly stored accessible to residents.
Food stored and prepared under unsanitary conditions; dish machine temperatures below required minimum.
Facility-wide assessment lacked evaluation of policies, contracts, and infection control program.
Staff failed to wear gowns when providing care to resident on enhanced barrier precautions.
Report Facts
Medication administration opportunities observed: 26
Medication errors observed: 3
Medication error rate: 11.54
Total census: 60
Brief Interview for Mental Status (BIMS) score: 7
Brief Interview for Mental Status (BIMS) score: 14
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in medication error findings related to withholding medications without physician orders |
| LPN #6 | Licensed Practical Nurse | Named in medication error findings related to missed medication administration |
| Director of Nursing | Director of Nursing | Provided medication administration policy and interviewed regarding medication errors and storage |
| Administrator | Administrator | Interviewed regarding resident funds, PASRR evaluation, and facility assessment |
| Activity Director | Activity Director | Interviewed regarding failure to provide one-on-one activities |
| Activities Assistant | Activities Assistant | Interviewed regarding frequency of one-on-one activities |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety, dish machine temperatures, and kitchen sanitation |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding improper medication storage in resident rooms |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Observed and interviewed regarding failure to wear gown during care of resident on enhanced barrier precautions |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Observed and interviewed regarding failure to wear gown during care of resident on enhanced barrier precautions |
| Licensed Practical Nurse #11 | Licensed Practical Nurse | Interviewed regarding resident dialysis and dressing care |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 8
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Hudson Memorial Nursing Home, including resident care, medication administration, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to convey resident funds timely after death, lack of proper PASRR evaluation coordination, inadequate provision of individual activities, medication errors exceeding 5%, improper medication storage, unsanitary food preparation conditions, incomplete facility-wide assessment, and failure to implement proper infection prevention practices.
Deficiencies (8)
Failed to convey a resident's personal funds within 30 days after death.
Failed to coordinate with state agency to obtain Level II PASRR evaluation for a resident.
Failed to provide individual activities consistently for a cognitively impaired resident.
Medication error rate was 11.54%, exceeding the 5% threshold during medication administration observation.
Medications and biologics were improperly stored in residents' rooms accessible to wandering residents.
Food was stored and prepared under unsanitary conditions; dish machine temperatures were below required minimums; pest control personnel did not wear beard covers.
Facility-wide assessment lacked evaluation of policies, contracts, and infection control program.
Staff failed to wear gowns while providing high contact care to a resident on enhanced barrier precautions.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Medication administration opportunities observed: 26
Medication errors: 3
Medication error rate: 11.54
Total census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in medication error findings related to withholding medications without physician orders |
| LPN #6 | Licensed Practical Nurse | Named in medication error findings related to missed medication administration |
| Director of Nursing | Director of Nursing | Provided medication administration policy and interviewed regarding medication errors and storage |
| Administrator | Facility Administrator | Interviewed regarding PASRR evaluation and resident funds handling |
| Activity Director | Activity Director | Interviewed regarding lack of one-on-one activities for Resident #35 |
| Activities Assistant | Activities Assistant | Interviewed regarding occasional one-on-one activities for Resident #35 |
| Dietary Manager | Dietary Manager | Interviewed regarding food sanitation and dish machine temperature issues |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Observed and interviewed regarding failure to wear gown during care of Resident #3 |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Observed and interviewed regarding failure to wear gown during care of Resident #3 |
| Licensed Practical Nurse #11 | Licensed Practical Nurse | Interviewed regarding Resident #3 dialysis and dressing care |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Oct 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, accurate resident assessments, respiratory care, and food safety at Hudson Memorial Nursing Home.
Findings
The facility was found deficient in maintaining resident privacy and confidentiality, accurately reflecting oxygen therapy in resident assessments, providing oxygen at prescribed flow rates with proper titration orders, and maintaining food temperatures on the steam table to prevent foodborne illness. All deficiencies were noted with minimal harm or potential for actual harm.
Deficiencies (4)
Failed to ensure privacy and confidentiality was maintained for 1 resident when a medication cart laptop screen was left open displaying resident information.
Failed to ensure the minimum data set accurately reflected oxygen therapy for 1 resident, potentially affecting 14 residents with oxygen orders.
Failed to ensure a resident was receiving oxygen at the flow rate ordered by the physician and failed to ensure oxygen titration orders included starting and maximum flow rates.
Failed to ensure food on the steam table was maintained at a temperature greater than 135 degrees Fahrenheit to prevent potential foodborne illnesses.
Report Facts
Residents sampled: 6
Residents affected: 14
Food temperatures: 150.8
Food temperatures: 140.5
Food temperatures: 183
Food temperatures: 191.5
Food temperatures: 136.3
Food temperatures: 126.4
Food temperatures: 123.4
Oxygen flow rate observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Mentioned in relation to leaving medication cart laptop screen open displaying resident information | |
| Director of Nurses | Interviewed regarding privacy and confidentiality policies | |
| MDS nurse | Interviewed regarding oxygen therapy documentation in MDS | |
| Assistant Director of Nursing (ADON) | Interviewed regarding oxygen flow rate and care plan for Resident #15 | |
| Dietary Employee #1 | Observed checking food temperatures on steam table | |
| Dietary Manager | Interviewed regarding food temperature standards and staff training |
Inspection Report
Routine
Deficiencies: 4
Date: Oct 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, accurate resident assessments, respiratory care, and food safety at Hudson Memorial Nursing Home.
Findings
The facility was found deficient in maintaining resident privacy and confidentiality, ensuring accurate Minimum Data Set (MDS) assessments reflecting oxygen therapy, providing safe and appropriate respiratory care with correct oxygen flow rates and titration orders, and maintaining proper food temperatures on the steam table to prevent foodborne illnesses.
Deficiencies (4)
Failed to ensure privacy and confidentiality was maintained for 1 resident when a medication cart laptop screen was left open displaying resident information.
Failed to ensure the MDS accurately reflected special treatments including oxygen therapy for 1 resident, potentially affecting 14 residents with oxygen orders.
Failed to ensure a resident was receiving oxygen at the flow rate ordered and failed to have oxygen titration orders with starting and maximum flow rates.
Failed to ensure food on the steam table was maintained at a temperature greater than 135 degrees Fahrenheit, with some pureed foods below 140 degrees.
Report Facts
Residents sampled: 6
Residents affected: 14
Food temperatures: 150.8
Food temperatures: 140.5
Food temperatures: 183
Food temperatures: 191.5
Food temperatures: 136.3
Food temperatures: 126.4
Food temperatures: 123.4
Oxygen order date: Nov 3, 2022
Oxygen order date: Dec 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in privacy violation for leaving laptop screen open |
| Director of Nurses | Director of Nurses | Interviewed regarding privacy and confidentiality policies |
| MDS nurse | Acknowledged oxygen therapy should have been added to MDS | |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about oxygen flow rates and care plan parameters |
| Dietary Employee #1 | Dietary Employee | Checked food temperatures on steam table |
| Dietary Manager | Dietary Manager | Interviewed about food temperature standards and staff training |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 21, 2022
Visit Reason
The inspection was conducted to assess compliance with feeding tube care protocols and infection prevention and control practices during medication administration at Hudson Memorial Nursing Home.
Findings
The facility failed to ensure feeding tube placement was verified before feeding for one resident with a feeding tube, and failed to ensure proper hand hygiene by Licensed Practical Nurses during medication passes, potentially affecting multiple residents.
Deficiencies (2)
Failed to ensure feeding tube placement was verified before feeding for Resident #22.
Failed to ensure Licensed Practical Nurses washed/sanitized hands between residents during medication passes, risking infection spread.
Report Facts
Residents affected: 1
Residents affected: 26
Medication pass observations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Observed failing to perform hand hygiene during medication pass | |
| Licensed Practical Nurse (LPN) #2 | Observed failing to check feeding tube placement and hand hygiene during medication pass | |
| Director of Nursing (DON) | Interviewed regarding feeding tube placement and hand hygiene policies |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 21, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations, focusing on feeding tube care and infection prevention practices.
Findings
The facility failed to ensure proper verification of feeding tube placement before feeding for one resident and failed to ensure proper hand hygiene by Licensed Practical Nurses during medication administration, potentially affecting multiple residents.
Deficiencies (2)
Failed to ensure feeding tube placement was verified before feeding for Resident #22.
Failed to ensure Licensed Practical Nurses washed or sanitized hands between residents during medication pass, risking infection spread.
Report Facts
Residents affected: 1
Residents affected: 26
Medication pass observations: 2
Halls: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Observed failing to perform hand hygiene during medication pass | |
| Licensed Practical Nurse (LPN) #2 | Observed failing to check feeding tube placement and hand hygiene during medication pass | |
| Director of Nursing (DON) | Provided information on feeding tube placement and hand hygiene policies |
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