Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hudson Memorial Nursing Home during CMS and state inspections, most recent first.
An LPN crushed medications into two liquid supplements for two residents and left both drinks unattended in the dining room. A resident with severe cognitive impairment picked up both supplements and drank from them, consuming medications prescribed for another resident. Staff observed medication residue in the drink and reported the incident to the RN supervisor and DON. The facility policy required residents to be identified before medication administration and observed afterward until doses were completely taken.
The facility's assessment failed to include evaluations of necessary policies, contracts, and infection control programs, potentially affecting all residents. The Administrator confirmed the absence of a policy for conducting the assessment.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 11.54%. Errors included withholding a calcium channel blocker from two residents with hypertension without documented physician orders and failing to administer an anti-flatulent medication to a resident with GERD. The facility's Medication Administration policy was not followed, contributing to these errors.
Two residents were found with medications improperly stored in their rooms, accessible to others. A cognitively intact resident had an unlabeled cream next to their bed, while another had wound cleanser and antifungal powder accessible. The ADON and DON acknowledged these items should not be left out, as per facility policy on medication storage.
The facility's kitchen operations were found deficient in maintaining sanitary conditions and proper temperature controls. Observations revealed dust on kitchen walls, improper water temperatures in the dish machine and 3-compartment sink, and expired test strips for sanitizer. Additionally, a pest control representative was seen without a beard cover, violating the facility's policy. The Dietary Manager acknowledged these issues, noting the importance of proper sanitization and adherence to policies.
A facility failed to convey a deceased resident's personal funds within the required 30-day period. The resident's trust account had a balance of $1,237.24, which was not distributed as per policy. The Administrator did not seek guidance from authorities when the resident's stepdaughter declined the funds, resulting in a deficiency.
A facility failed to coordinate with the state agency to obtain a Level II PASRR evaluation for a resident with cerebral palsy. The resident's health record lacked the necessary evaluation report, and the care plan did not include PASRR information. Despite the DON providing a guide indicating the need for a Level II PASRR, the facility did not secure the evaluation, resulting in a deficiency.
A facility failed to consistently offer individual activities to a resident with depression, anxiety, and severe cognitive impairment. The resident was often found lying in bed with the TV off, and interviews revealed that one-on-one activities were not regularly provided. The last documented activity was over a week prior, despite the care plan and facility policy requiring such engagement.
A resident with moderate cognitive impairment and end-stage renal disease was observed receiving a bed bath from two CNAs who did not wear gowns, despite the requirement for enhanced barrier precautions. Interviews confirmed staff awareness of the PPE policy, but it was not followed during the care activity.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure residents were supervised during medication administration when crushed medications were placed in liquid supplements. Resident #1 had diagnoses including non-Alzheimer's dementia and a BMI of 19 or less, and the quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment. The resident required set up with eating and supervision/touch for mobility, and was documented as oriented to person, confused, and having impaired memory. On 10/23/2025, LPN #1 crushed an expectorant and a medication used to treat the symptoms of Alzheimer's dementia into one supplement, and crushed an antianxiety medication and an antidepressant into another supplement for two residents in the dining room. LPN #1 handed one supplement to the intended resident and placed the other on a dining room table next to that resident, then left without watching either resident take the medications. Resident #1, who was in the dining room, picked up both supplements and drank from them, consuming medications that had been prescribed for another resident. A CNA observed Resident #1 drinking from the supplements and saw medication residue around the container. The incident was reported to the RN Supervisor and DON, and the APRN was notified. Interviews confirmed that LPN #1 did not stay with the residents until the medications were taken, and the DON stated the nurse had been instructed that if medications were crushed into a liquid supplement, the nurse should remain with the resident until all medication was consumed. The facility policy stated residents are identified before medication administration and observed after to ensure doses are completely taken.
Deficient Facility-Wide Assessment
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included essential information to allocate necessary care and resources to meet the residents' needs. The assessment, dated 07/11/2024, was reviewed with the Quality Assessment and Assurance and Quality Assurance and Performance Improvement (QAA/QAPI) committee on 07/12/2024. However, it lacked an evaluation of required policies and procedures for care provision, an evaluation of contracts and third-party agreements for goods and services, and a description of how the facility would evaluate its infection prevention and control program. During an interview on 12/19/2024, the Administrator stated that an entire team contributes to the facility assessment but admitted that the facility did not have a policy for conducting the assessment.
Medication Administration Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.54% during medication administration. This deficiency was identified during the observation of medication administration to six residents by two LPNs. Specifically, three out of 26 medication administrations were not conducted according to physician's orders. For instance, an LPN withheld a calcium channel blocker from two residents with hypertension, despite the absence of any physician's order parameters to hold the medication based on blood pressure readings. The LPN claimed to have received verbal instructions from a physician to hold the medication under certain conditions, but these instructions were not documented in the residents' orders. Additionally, another LPN failed to administer an anti-flatulent medication to a resident with gastroesophageal reflux disease (GERD) as per the physician's order. The LPN acknowledged missing the medication after reviewing the electronic medication administration record (eMAR), which indicated the medication was administered. The facility's Medication Administration policy, which emphasizes the importance of following physician's orders and the six rights of medication administration, was not adhered to in these instances.
Improper Storage of Medications and Biologics
Penalty
Summary
The facility failed to ensure proper storage of medications and biologics for two residents, leading to a deficiency. Resident #40, who was cognitively intact with a BIMS score of 14, was observed with an unlabeled white cream in a medication cup on the shelf next to their bed. The Assistant Director of Nursing (ADON) could not confirm the identity of the cream but acknowledged it should not have been accessible to residents, as it could be grabbed by others. Similarly, Resident #37, also cognitively intact with a BIMS score of 15, was found with wound cleanser and antifungal powder on the shelf next to their bed. The ADON noted that items labeled 'keep out of reach of children' should not be left out in the open. The Director of Nursing (DON) confirmed that medications should not be stored in residents' rooms where they are accessible to wandering residents. The facility's policy on medication storage emphasizes the need for safe, secure, and orderly storage of medications.
Sanitation and Temperature Control Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was stored and prepared under sanitary conditions, as observed in the kitchen. The kitchen walls, including those near the food preparation area and above the 3-compartment sink, were covered with brownish-gray, fine, powdery particles. The Dietary Manager (DM) confirmed that the particles were dust and acknowledged the importance of keeping the walls clean to prevent contamination of food. Additionally, the cleaning schedules did not include provisions for cleaning the walls to remove dust. The 3-compartment sink and dish machine were not maintained at the required temperatures for proper sanitization. Dietary Employees (DE) #1, #2, and #3 were observed using the dish machine and 3-compartment sink without ensuring the water temperatures met the manufacturer's minimum requirements of 120 degrees Fahrenheit for both wash and rinse cycles. DE #2 and DE #3 were unable to demonstrate proper testing of water temperatures and sanitizer effectiveness, and the test strips used were expired. The contracted pest control representative was observed in the kitchen without a beard cover, despite having a full beard approximately 6 inches in length. The facility's policy required facial hair to be covered, but the representative bypassed the available beard covers. The DM acknowledged the policy and stated that the vendor was managed by another person. The DM also stated that all employees operating the dish machine should know how to test the machine's temperatures and sanitizer, but this was not the case. The DM mentioned that maintenance had adjusted the dish machine's temperature, but it still did not meet the required levels. The DM indicated that the vendor would need to be contacted regarding the dish machine's temperature inaccuracies.
Failure to Convey Deceased Resident's Funds
Penalty
Summary
The facility failed to convey a deceased resident's personal funds to the individual or representative administering the estate within the required 30-day period. The Bookkeeper provided documentation indicating that the trust account for the resident had a closing balance of $1,237.24. Despite the resident's passing, the funds were not distributed as per the facility's policy, which mandates that upon a resident's death, their funds should be conveyed to the appropriate party within 30 days. The Bookkeeper stated that the facility had four days to return a resident's money from a trust account upon discharge or death, but this was not adhered to in the case of the deceased resident. The Administrator mentioned that the resident's stepdaughter did not want the funds returned to her, and there was no other contact person. Furthermore, the Administrator did not seek guidance from the governing body or state authority on how to handle the remaining funds, leading to the deficiency.
Failure to Obtain Level II PASRR Evaluation for Resident with Cerebral Palsy
Penalty
Summary
The facility failed to coordinate with the appropriate state agency to ensure a Level II Pre-Admission Screening and Resident Review (PASRR) evaluation report was obtained for a resident with cerebral palsy, who was reviewed for a Level II PASRR. On December 17, 2024, it was discovered that the resident's electronic health record lacked a Level II PASRR evaluation report. The Director of Nursing (DON) provided a document indicating that the resident could not be admitted until a Level II PASRR was completed, but the document did not include the necessary evaluation. The resident's care plan, dated December 6, 2024, also lacked PASRR information, despite the resident having a communication problem related to cerebral palsy and intellectual disabilities. The Administrator was unable to locate the Level II PASRR evaluation for the resident and later found information from another state agency but did not provide it for review. The DON provided an undated document used as a guide for Level II PASRR screening, which indicated that clients with developmental disabilities, such as cerebral palsy, required a Level II PASRR. However, the facility did not follow through with obtaining the necessary evaluation, leading to a deficiency in coordinating with the state agency to ensure the resident received the appropriate services.
Failure to Provide Consistent Individual Activities
Penalty
Summary
The facility failed to consistently offer individual activities to a resident, identified as Resident #35, who was reviewed for activities. Resident #35 was observed on multiple occasions lying in bed with eyes closed, and the television was off. The resident had diagnoses of depression and anxiety and was severely cognitively impaired, requiring assistance for emotional, intellectual, physical, and social needs. The care plan for Resident #35 indicated the need for one-on-one bedside or in-room activities if unable to attend out-of-room events. Interviews with the Activity Director (AD) and Activities Assistant (AA) revealed that one-on-one activities were not consistently provided. The AA mentioned visiting the resident approximately twice a week but would not wake the resident if they were asleep. Documentation indicated that the last recorded activity for Resident #35 was on 12/06/2024, despite the facility's policy stating that individual activities should be provided for residents unable to participate in other activities. This lack of consistent engagement led to the deficiency noted in the report.
Failure to Use Proper PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff applied the proper personal protective equipment (PPE) while providing high-contact care to a resident on enhanced barrier precautions (EBP). The resident, who had a moderate cognitive impairment and was receiving dialysis due to end-stage renal disease, was observed receiving a bed bath from two certified nursing assistants (CNAs) who were not wearing gowns, despite the presence of an EBP sign indicating the need for such precautions. Interviews conducted with the CNAs and the Director of Nursing (DON) confirmed that the staff were aware of the requirement to wear gowns and gloves when providing care to residents on EBP. The facility's policy on EBP clearly stated that gloves and gowns must be worn for high-contact resident care activities, including bathing. However, the CNAs did not adhere to this policy during the observed care of the resident.
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What surveyors actually found near you
We read the 9 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Dorado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timberlane Health & Rehabilitation | 0.6 mi | ★★★★★ | 1 | 0 |
| Courtyard Rehabilitation And Health Center, Llc | 1.5 mi | ★★★★★ | 4 | 0 |
| The Springs Of El Dorado | 2 mi | ★★★★★ | 2 | 0 |
| Oak Ridge Health And Rehabilitation | 2 mi | ★★★★★ | 2 | 0 |
| Silver Oaks Health And Rehabilitation | 25.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.