Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hudson Elms Nursing Center during CMS and state inspections, most recent first.
Kitchen sanitation and food labeling failures were observed when staff found unlabeled and improperly dated food items, dirty shelving and equipment, dust buildup on vents, and debris behind the ice machine. Moldy strawberries were found in the walk-in refrigerator, and a rotting, moldy wall near the dishwasher area was associated with a strong odor and fruit flies.
Broken Walk-In Freezer Affects Meal Preparation The kitchen walk-in freezer was found broken, with frozen items being stored in two standing freezers in the beverage area. The KD, Regional KD, and RD stated the freezer had been broken for months, and the KD reported he was substituting many food items because there was no freezer space. Pork planned for dinner was not served because there was no freezer to store it, and dinner was instead ham and cheese sandwiches.
Unclean and damaged resident areas and smoking space. Surveyors observed peeling paint, holes in walls, exposed drywall, broken tiles, ceiling damage, stains, dust, and damaged furniture in multiple resident rooms, hallways, bathrooms, and the dining room. In the smoking area, more than 25 cigarette butts were seen on the ground and in the rocks while multiple residents were present, and the AD confirmed the area was not maintained in a clean manner.
Failed kitchen pest control management was identified after surveyors observed multiple fruit flies around trash cans, in the dishwashing area, and on the tray line near brownies being served to residents. The RD also reported fruit flies in the ceiling, lights, and behind wallpaper near the dishwasher area, while the RKD described a rotting, moldy wall and a bad odor. An Orkin report noted food debris and buildup in drains, the door track, and the garbage disposal, with ongoing fly activity tied to these conditions.
An LPN worked 33 days while his nursing license was suspended, and the facility did not know the license had been suspended because he did not notify anyone. State licensure review and confirmation from the OBN verified the LPN did not have an active license.
Failure to Act on Pharmacy Recommendations: Pharmacy recommendations for several residents’ med regimens were left unanswered for an extended period, with no timely response or documented justification for declining them. Staff interviews also described concerns about a physician’s narcotic prescribing practices and noted that the facility’s QAPI findings identified delays and inaccuracies in GDRs and pharmacy recommendations.
Pharmacy review recommendations were not acted on timely and GDR refusals lacked documented clinical justification for several residents. A resident with psych diagnoses remained on zolpidem without a stop date despite repeated pharmacist recommendations, another resident had an incorrect potassium order and concurrent psychotropics without a documented GDR rationale, and two residents had multiple opioid orders or duplicate opioid therapy that were not clearly reconciled. DON, MD, and the consultant pharmacist confirmed the issues.
PASRR forms for multiple residents did not accurately reflect documented psychiatric diagnoses. Surveyors found that residents with diagnoses such as bipolar disorder, schizoaffective disorder, major depressive disorder, schizophrenia, delusional disorder, anxiety, and intellectual disabilities had PASRR screens or notices marked as having no serious mental illness or otherwise listing incomplete diagnoses. The SSD confirmed the PASRRs were not accurate.
A facility failed to ensure influenza and pneumococcal vaccines were educated on, offered, and/or administered as ordered for four of five residents reviewed for immunizations. Records for residents with diagnoses including cognitive impairment, schizoaffective disorder, diabetes, renal dialysis, cellulitis, bipolar disorder, and heart failure did not show vaccine education, consent, or documentation that the vaccines were given, and the DON confirmed the missing evidence.
A facility failed to ensure COVID-19 vaccine education, consent, and documentation were completed for four residents reviewed for immunizations. The EHRs did not show the vaccine as given, and the RN Travel DON confirmed there was no evidence the residents were educated on vaccine use, consents were obtained, or the vaccine was offered and/or administered; the affected residents included individuals with both intact and impaired cognition and diagnoses such as schizoaffective disorder, cancer, diabetes, dialysis dependence, bipolar disorder, and heart failure.
The facility failed to develop and implement individualized interventions to prevent repeated resident-to-resident physical abuse between two cognitively intact residents. One resident with schizoaffective disorder, MDD, and HTN and another resident with COPD, bipolar disorder, and alcohol dependence were involved in two separate altercations: one in a smoke line after threats were made, and another in a hallway where one resident was struck in the face and his glasses were broken. Records showed no additional individualized interventions beyond short-term 15-minute checks after the first incident.
Failure to provide timely incontinence care: A resident with multiple chronic conditions, including CVA, HF, COPD, and anxiety, was documented as resistive to ADL care and occasionally incontinent. After falling from his wheelchair, he urinated on himself and was found on the floor with urine, feces, and blood saturating his clothing; EMS estimated he may have been down longer than staff reported. The record contained no evidence of cleanup refusal documentation or interventions related to his refusal of toileting and hygiene care.
A facility failed to complete required quarterly pain assessments for residents on narcotic pain meds and failed to administer scheduled narcotic pain doses as ordered for one resident. One resident with dementia had a missing quarterly pain assessment, another resident with an amputation stump and COPD missed three scheduled hydrocodone-acetaminophen doses when the med was not available, and a third resident with dementia and schizoaffective disorder had multiple missing quarterly pain assessments. The DON and RN confirmed the missed assessments and doses.
Infection Control Failure During Wound Care: A resident with a left BKA and an order for stump wound care was observed during a dressing change in which the DON used a visibly dirty bedside table without cleaning it first, placed bathroom paper towels on it as a barrier, removed the old dressing with gloves on, and then cleaned the wound without removing the gloves or washing hands. New gloves were later placed partly on the barrier paper and partly on a dirty remote-control device, and the DON confirmed the observation.
Nonfunctioning resident call lights were identified for three residents, and resident council members reported nighttime response times were sometimes over two hours. One resident said his call light had not worked for three weeks, another was observed with a bedside cord that activated the station light but not the corridor dome light and a missing cover, and a third resident reported having no functioning call light. Facility policy required call lights to be plugged in and functioning at all times.
A resident with dementia, hyperlipidemia, and HTN was sent to the hospital after coffee ground emesis during morning care. The facility did not have evidence that the resident or representative received written notice of the reason for discharge in a language the resident understands or a bed hold policy showing the remaining bed hold days and return process; the SSD confirmed the record lacked this documentation.
Meals Not Served in Accordance With Ordered Double Portions: The facility failed to serve meals in a form designed to meet individual needs for two residents. One resident with COPD, bipolar disorder, and alcohol dependence had an order and meal ticket for double portions, but observations and the DON confirmed the lunch tray did not include them. Another resident with bipolar disorder, HTN, and diabetes also had an order for double portions, yet observations, a CNA, and the DON confirmed the resident’s trays did not provide the ordered double portions.
Menu Not Followed and Substitution Log Missing: The facility did not follow the posted weekly menu and could not produce a substitution log. Staff served meals that differed from the planned entrees and sides, including a hamburger meal instead of the listed supper options and a BBQ rib patty meal with different sides than the menu showed. The KD and RKD stated substitutions were made because the freezer was broken and items could not be stored, and the RKD could not find the substitution log.
Several residents with complex medical conditions did not consistently receive restorative nursing services as outlined in their care plans, including ambulation, ROM exercises, and ADL support. Documentation frequently showed missed or unperformed interventions, and staff interviews confirmed a lack of knowledge and inconsistent implementation, affecting the residents' functional maintenance.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with a history of psychiatric disorders and self-harm accused an RN of abuse, but the allegation was not reported promptly as required by facility policy. The incident was only discovered days later after the resident was hospitalized for intentional self-harm and reported feeling abused. The RN did not report the comment, citing the resident's frequent similar remarks.
A resident with multiple health issues did not receive prescribed Lyrica for pain management due to unavailability upon admission. The resident missed three doses, causing distress, and the medication was only administered two days later. Staff interviews confirmed the delay and the resident's dissatisfaction.
A facility failed to ensure a resident had physician orders for BiPAP and did not schedule a diagnostic test for obstructive sleep apnea. Despite discussions and approvals during a care conference, the resident's BiPAP was not used, and the sleep study was not scheduled, leading to a lapse in respiratory care.
A resident with multiple health conditions alleged that an STNA hit him, but the facility's investigation was incomplete, lacking thorough documentation of resident and staff interviews. The facility's policy requires thorough investigation and documentation of such incidents, which was not met in this case.
Kitchen sanitation and food labeling failures
Penalty
Summary
The facility failed to maintain the kitchen in a clean, sanitary manner and failed to ensure food was stored and labeled properly. During an initial kitchen tour, the Kitchen Director observed a container of pork and beans dated 04/28/26, an unlabeled potato salad container, unlabeled pitchers of orange Kool-Aid and purple Kool-Aid, and a container of pork that was dated but unlabeled. The wall behind the bread shelf storage had dried splatters, there were crumbs and debris on tray line shelving, the standing refrigerator by the Kitchen Director’s office had crumbs and splatters, and multiple kitchen vents had visible dust buildup. The Kitchen Director confirmed these observations and stated the facility keeps leftovers for 2 days. Further observations in the kitchen revealed dirt and trash behind the ice machine, including tape and a Styrofoam cup, and multiple moldy strawberry containers in the walk-in refrigerator. The Regional Kitchen Director stated the strawberries had been delivered the night before and discarded the entire carton. A hole was observed in the wall behind the 3-part sink from a pipe bursting. Later, a very strong odor was noted by the dishwasher area, and the wall between the beverage area and dishwasher area was described as rotting and moldy. The Regional Kitchen Director stated the facility had contacted a company to replace the wall and said this was causing the fruit flies and strong odor.
Broken Walk-In Freezer Prevented Proper Food Storage and Meal Service
Penalty
Summary
The facility failed to ensure the kitchen walk-in freezer was in functional working condition. During an initial kitchen tour, the Kitchen Director observed that the large walk-in freezer was broken, and frozen items were being stored in two standing freezers in the beverage area. On a later observation and interview, the Kitchen Director, Regional Kitchen Director, and Registered Dietitian stated the freezer had been broken for a few months. The Kitchen Director said he was substituting many food items because there was no freezer, and he reported that pork planned for dinner had to be substituted because there was no freezer space to store it. The Regional Kitchen Director stated the facility had received nine quotes for the freezer repair. Later that day, dinner was served as ham and cheese sandwiches, and the Kitchen Director stated he did not have a freezer to store the pork and that residents do not like pork.
Unclean and Damaged Resident Areas and Smoking Space
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment. During observation and interview, paint was peeling above the floorboard by the window in a room shared by Residents #5 and #2, and a white wooden cover under the window in Resident #10’s room was being held up with black duct tape. In Resident #11’s room, four 1/2-inch by 1/2-inch holes were observed in the wall with crumbling drywall exposed below the window and above the heat register; the resident stated the holes were from a shelf removed 3 years earlier and had never been fixed. Additional concerns identified during the facility tour included a missing section of privacy curtain track above bed 2 in Resident #10’s room, broken wall tiles in the central bathroom on the 100 Hall, a large area of peeled popcorn ceiling in Resident #44’s room, a 1 foot by 1 foot water stain on the ceiling in Resident #26’s room, dried liquid stains on the wall between a room and Room #205 by the floor vent, dried stains and dust along hallway handrails, peeling paint and exposed drywall near the central bath on the 200 Hall, multiple drywall patches in Resident #21’s room that had not been painted over, and dining room chairs with unbolted or missing arm rests. The smoking area was also observed to be unclean. During the resident smoke break, more than 25 cigarette butts were seen on the ground and in the rocks of the smoking area while Residents #2, #4, #7, #9, #13, #14, #17, #23, #24, #31, #35, #36, #37, #39, #40, and #56 were present. The Activities Director confirmed the smoking area had a large number of cigarette butts on the ground and was not maintained in a clean manner. Review of the smoker list showed 23 residents currently smoked, and the facility census was 43. The facility policy stated that staff and management maximize characteristics of a personalized, homelike setting, including a clean, sanitary, and orderly environment.
Failed Kitchen Pest Control Management
Penalty
Summary
The facility failed to maintain an effective pest control management system in the kitchen. During an initial kitchen tour, the beverage area had multiple fruit flies flying around a covered trash can, and when the lid was lifted, numerous fruit flies flew out of the trash can. In the dishwashing area, an uncovered trash can with no bag and a piece of bread inside also had fruit flies present. During a later observation of the dinner tray line, numerous fruit flies were seen around brownies that were on the tray line and being served to residents. The Registered Dietitian reported observing fruit flies in the kitchen ceiling, ceiling lights, and behind the wallpaper by the dishwasher area. Staff stated the drains were flushed weekly with an enzyme cleaner, and the dishwasher area had a bad smell. The Regional Kitchen Director reported the wall between the beverage area and dishwasher area was rotting and moldy and said this was the cause of the strong odor and fruit fly issue. An Orkin service report noted drains were foamed to break down organic material causing drain and phorid fly activity, with food debris and buildup present in floor drains, the track of the pull-down door, and the garbage disposal. The facility policy stated routine pest control procedures would be in place and that pests seen in the kitchen would be reported and addressed.
LPN Worked With Suspended License
Penalty
Summary
The facility failed to ensure LPN #853 had a valid and active nursing license. Review of the State licensure database showed the LPN did not have an active license, and email correspondence from the Chief of Compliance at the Ohio Board of Nursing verified that the license had been suspended and remained suspended. The report states the suspension began on 11/20/25. Review of LPN #853’s time punches showed he worked 33 days while his nursing license was suspended, including multiple shifts from late November 2025 through March 2026. Interview with the Administrator and the Regional Director of Clinical Services confirmed the facility did not know the license was suspended because LPN #853 did not notify anyone of the suspension.
Failure to Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to implement a quality assurance plan to ensure resident pharmacy recommendations were acted upon in a timely manner. Record review for Residents #2, #4, #5, and #40 showed ongoing pharmacy recommendations beginning in July 2025 to modify their medication administration regimens, but there was no timely response and no justification documented for declining the recommendations from Physician #854. Telephone interviews with the consultant pharmacist and another physician indicated concerns about Physician #854’s narcotic prescribing practices, including use of narcotics for residents with no clear indication and repeated counseling about those practices. Review of the facility’s QAPI policy showed expectations for continuous evaluation of systems and identification of issues, and the QAPI report dated 05/06/26 stated that GDRs and pharmacy recommendations were not being completed timely and accurately. Interviews on 05/12/26 with the Administrator, RN Regional Director of Clinical Services #860, Regional Director of Operations #862, and Regional MDS #855 revealed that QA met quarterly to discuss resident care and that QAPIs were implemented during the survey for narcotics at the lowest effective dose and for GDR and pharmacy recommendations to be addressed timely.
Pharmacy Recommendations Not Timely Addressed and GDR Justification Missing
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review was acted upon in a timely manner and that pharmacy recommendations included a valid reason when a gradual dose reduction (GDR) was not attempted. This deficiency involved four residents out of 11 records reviewed for unnecessary medications, and the facility census was 43. The report states that the facility’s policy required each resident’s entire medication regimen to be managed and monitored to promote or maintain the resident’s highest practicable well-being free from unnecessary drugs. For one resident with schizoaffective disorder, anxiety, major depressive disorder, and insomnia, the record showed an order for zolpidem (Ambien) 10 mg as needed for sleep. The consultant pharmacist twice recommended discontinuation of the medication or adding a stop date because the order had no stop date. The first recommendation was dated 02/20/26 and the second 03/22/26, but the recommendation was not acted upon until 04/13/26. The DON confirmed the pharmacy recommendations were not addressed timely. For another resident with dementia, schizophrenia, intellectual disabilities, hallucinations, and delusional disorder, the record showed a potassium order entered with instructions that did not match the medication strength, and the pharmacist recommended correcting the dose to potassium 10 mEq daily. The report states there was no evidence the recommendation was acted upon. The same resident also had two antidepressants ordered for different indications, and the pharmacist recommended considering a GDR of one or both agents or documenting a rationale for continued use of two psychotropics from the same therapeutic class. The physician response was marked “other” and would review, but the DON confirmed the paroxetine was discontinued and reordered at the same dose and trazodone was not adjusted without justification to decline the recommendation. For a resident with paraplegia, anxiety disorder, and major depressive disorder, the record showed multiple oxycodone orders with no clear indication or sequence for administration. The pharmacist recommended discontinuing one oxycodone order and retaining the 5 mg as-needed orders, but the two-tablet as-needed order was not discontinued as indicated. For another resident with schizoaffective disorder, alcohol dependence with alcohol-induced persisting dementia, and Alzheimer’s disease, the record showed escalating opioid therapy and duplicate opioid use. The pharmacist recommended decreasing narcotics and later recommended discontinuing Dilaudid and adjusting oxycodone, but the physician response did not include clinical justification for refusing the GDR or for continuing Dilaudid instead of oxycodone, and the recommendation was not addressed until 23 days later. Interviews with the DON, consultant pharmacist, MD, and another physician confirmed concerns about the narcotic prescribing and the lack of timely action on pharmacy recommendations.
PASRR forms did not match residents’ psychiatric diagnoses
Penalty
Summary
The facility failed to ensure PASRR forms accurately reflected residents’ psychiatric diagnoses for six of seven residents reviewed for PASRR requirements. Surveyors found that multiple PASRR Identification Screens and PASRR Result Notices listed no indications of serious mental illness or developmental disability, or otherwise did not match the residents’ documented diagnoses in the medical record. The affected residents included individuals with diagnoses such as bipolar disorder, schizoaffective disorder, major depressive disorder, schizophrenia, delusional disorder, anxiety, and intellectual disabilities. For one resident, the medical record showed diagnoses including bipolar disorder, borderline personality disorder, major depressive disorder recurrent, suicidal ideations, and a history of suicidal behavior, but the PASRR Identification Screen dated 03/19/26 stated there were no indications of serious mental illness or developmental disability effective 03/18/26. Another resident admitted with schizoaffective disorder bipolar type, vascular dementia, altered mental status, and unspecified psychosis had a PASRR Identification Screen dated 03/26/24 that also indicated no serious mental illness or developmental disability. A third resident’s PASRR Identification Screen dated 03/11/26 listed a mood diagnosis, but did not reflect the documented major depressive disorder. Additional records showed a resident admitted with schizoaffective disorder, anxiety, and major depressive disorder had a PASRR Result Notice dated 11/08/24 stating no indications of serious mental illness or developmental disability. Another resident admitted with dementia, schizophrenia, intellectual disabilities, hallucinations, and delusional disorder had a PASRR completed on 04/24/23 that marked “No” to whether the individual had a diagnosis of mental disorders listed on the form. A sixth resident admitted with bipolar disorder, depression, anxiety, and schizoaffective disorder had a PASRR completed on 04/02/26 that also marked “No” to the question about diagnoses of listed mental disorders. The Social Service Designee confirmed during interview that the PASRRs were not accurate for these residents.
Failure to Provide Influenza and Pneumococcal Vaccine Education and Offerings
Penalty
Summary
The facility failed to ensure residents were provided education on influenza and pneumococcal vaccinations and that the vaccinations were offered and/or administered as ordered. This deficiency affected four of five residents reviewed for immunizations in a census of 43. Review of the medical records for Residents #2, #3, #23, and #31 showed that influenza and pneumococcal vaccines were not listed as given in the electronic health record, and the records did not contain evidence that vaccine education was provided or that consent for vaccination was obtained. Resident #2 was admitted with diagnoses including schizoaffective disorder, generalized anxiety disorder, and major depressive disorder, and the admission MDS showed moderate cognitive impairment. Resident #3 was admitted with diagnoses including malignant neoplasm of the border of the tongue, alcohol abuse, and adult failure to thrive, and the quarterly MDS showed moderate cognitive impairment. Resident #23 was admitted with diagnoses including schizoaffective disorder bipolar type, diabetes, and dependence on renal dialysis, and the admission MDS showed intact cognition. Resident #31 was admitted with diagnoses including cellulitis of the left lower limb, bipolar disorder, and heart failure, and the admission MDS showed intact cognition. The RN Travel DON confirmed for each of these residents that the records did not show vaccine education, consent, or evidence that the vaccines were offered and/or administered as required.
Missing COVID-19 Vaccine Education, Consent, and Documentation
Penalty
Summary
The facility failed to ensure residents were educated on COVID-19 vaccination and that the vaccine was offered and/or administered as ordered, with documentation missing for four of five residents reviewed for immunizations. Resident #2 was admitted with schizoaffective disorder, generalized anxiety disorder, and major depressive disorder, and the admission MDS showed moderate cognitive impairment. Resident #3 was admitted with malignant neoplasm of the border of the tongue, alcohol abuse, and adult failure to thrive, and the quarterly MDS showed moderate cognitive impairment. Resident #23 was admitted with schizoaffective disorder bipolar type, diabetes, and dependence on renal dialysis, and the admission MDS showed intact cognition. Resident #31 was admitted with cellulitis of the left lower limb, bipolar disorder, and heart failure, and the admission MDS showed intact cognition. Review of each resident’s EHR showed the COVID-19 vaccination was not listed as given. During interview, the RN Travel DON confirmed the medical records for Residents #2, #3, #23, and #31 did not contain evidence that the residents were educated on COVID-19 vaccine use, that consents for COVID-19 vaccines were obtained, or that the vaccines were offered and/or administered. The facility’s Coronavirus (COVID-19) Policy, revised 05/10/23, stated that the protection of residents and staff was the top priority and that the facility had developed a proactive plan designed to minimize the impact of COVID-19 within the facility.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure individualized interventions were developed and implemented to prevent resident-to-resident physical abuse between two residents. One resident had diagnoses including schizoaffective disorder, major depressive disorder, and essential hypertension, and had intact cognition on a quarterly MDS assessment. The other resident had diagnoses including COPD, bipolar disorder, and alcohol dependence, and also had intact cognition on a quarterly MDS assessment. Two separate physical altercations occurred between these residents. In the first incident, one resident struck the other after a dispute in the smoke line, following threats to punch him; the incident was investigated and found unsubstantiated for physical abuse. In the second incident, the same resident struck the other in the face in the hallway because he felt the other resident was going too slow; the resident who was struck reported being blocked in the hallway and then hit in the face with a closed fist, breaking his glasses. Review of the records showed no additional individualized interventions were implemented beyond short-term 15-minute checks after the first incident, and the facility acknowledged the two resident-to-resident incidents occurred.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Resident #43 was admitted with diagnoses including cerebral infarction, heart failure, acute respiratory failure with hypoxia, tobacco use, alcohol abuse, hypertension, chronic obstructive pulmonary disease with acute exacerbation, generalized anxiety disorder, shortness of breath, asthma, and a personal history of pulmonary embolism. His care plan documented that he was resistive to care, including refusing showers, changing clothes, incontinence care, wound care, and sleeping in his bed. The care plan interventions included allowing him to make decisions about treatment, encouraging participation during care, giving clear explanations, praising appropriate behavior, maintaining consistency in ADLs, and providing opportunities for choice during care provision. The quarterly MDS indicated he required partial to moderate assistance with toileting hygiene, substantial to maximum assistance with bathing, was not on a toileting program, and was occasionally incontinent of urine and bowel. A nursing note documented that after the resident fell out of his wheelchair and onto the floor, he urinated on himself and the urine was mixed with blood. The resident was unable to be lifted from the floor and 911 was called for transport to the hospital. The medical record contained no evidence that he refused cleanup after becoming incontinent on the floor or that interventions were implemented related to refusing ADL care. The prehospital care report stated he was found lying supine on the floor with pants saturated with urine, feces, and blood, and EMS estimated he may have been on the floor longer than staff reported. A confidential concern submitted to the State Agency stated he arrived at the hospital with a saturated brief and concerns of possible neglect, and an LPN later stated he had refused toileting and hygiene care and presented incontinent of urine.
Missed Pain Assessments and Scheduled Narcotic Doses
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for residents who required pain services. For one resident with unspecified dementia, anxiety disorder, and essential hypertension, the record showed quarterly pain assessments were not completed, including a missing assessment for 02/2026. The resident’s pain care plan directed staff to administer analgesia as ordered, anticipate pain needs, identify and record pain history, monitor for causes of pain episodes, and monitor and report signs of non-verbal pain. The Regional Director of Clinical Services confirmed the missing quarterly pain assessment, and the facility pain policy required pain assessments on admission, at quarterly review, with significant condition changes, and with new or worsening pain. For another resident with complications of an amputation stump, COPD, and bipolar disorder, physician orders included multiple pain medications, including scheduled hydrocodone-acetaminophen every six hours. The MAR/TAR review showed the resident did not receive the scheduled narcotic doses at midnight, 6:00 A.M., and 12:00 P.M. on 05/06/26. A progress note documented that the resident requested the midnight narcotic, was told it was not available because it had not been reordered and the facility was waiting for pharmacy delivery, then became visibly upset, threw items from the bedside table, pushed the tablet across the room, lowered herself to the floor, and was observed yelling in the hallway. The RN Regional Director of Clinical Services confirmed the missed doses, and the DON stated staff needed authorization to pull narcotics from the pyxis and that the narcotic pain medication was ordered the next day when it was discovered the resident did not have more medication available. For a third resident with schizoaffective disorder, alcohol dependence with alcohol-induced persisting dementia, and Alzheimer’s disease, quarterly pain assessments were also not completed as required. The record showed only one quarterly pain assessment was present, with missing assessments for 05/2025, 11/2025, and 02/2026. The resident’s pain care plan directed staff to administer analgesics as ordered, anticipate pain needs, respond immediately, and monitor for non-verbal pain. The Regional Director of Clinical Services confirmed the missing quarterly pain assessments, and the facility pain policy again required pain assessment at admission, quarterly review, significant change, and onset or worsening of pain.
Infection Control Failure During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care for Resident #31, who was admitted with diagnoses including acquired absence of the left leg below-knee amputation (BKA). The resident had an order to cleanse the left stump with soap and water, pat dry, apply Santyl and an abdominal pad, and cover with kerlix. During observation of the wound care and dressing change with the DON, the bedside table was visibly dirty and was not cleaned or wiped down with an antiseptic cloth before two paper towels from the resident’s bathroom were placed on it as a barrier. During the dressing change, the DON removed the old dressing by pulling tape from the top of the dressing closest to the resident’s knee and then pulling the rest off the stump while wearing gloves. The old dressing was discarded, and the DON then grabbed wound cleaner, sprayed the wound, and began cleaning it with 4x4 gauze without removing the old gloves or washing her hands. The gauze used to clean the surgical site was thrown away with the gloves. After washing her hands and applying new gloves, the gloves were placed partly on the barrier paper, with the fingers resting on a dirty remote-control device. The DON confirmed the observation after the dressing change.
Nonfunctioning Resident Call Lights
Penalty
Summary
The facility failed to ensure resident call lights were in working order in resident bathrooms and bathing areas, affecting Residents #6, #9, and #41. Resident council members reported that call light response times at night were sometimes over two hours. Resident #41 stated his call light had not worked for three weeks, and when the bedside call cord was tested, the bedside station light activated but the corridor dome light outside the room did not light up. Resident #6 was observed with the same condition when the bedside call cord was tested, and the corridor dome light outside the room did not light up; the light was also missing its cover. Resident #9 stated he did not have a functioning call light, and the Regional Traveling Administrator said maintenance would get the resident a bedside call cord. The facility policy stated that call lights should be plugged in and functioning at all times and defective call lights should be reported promptly.
Missing discharge notice and bed hold information
Penalty
Summary
The facility failed to ensure Resident #48 was provided written notification, in a language the resident understands, stating the reason for discharge to the hospital, and failed to provide a bed hold policy that included the bed hold days remaining and the process for returning to the facility. Resident #48 was admitted, later readmitted, and then discharged to the hospital with diagnoses including unspecified dementia, hyperlipidemia, and essential hypertension. The resident did not return to the facility. Review of the record showed the resident had moderate cognitive impairment on the admission MDS 3.0 assessment. On 02/24/26 at 5:24 A.M., during morning care, the resident had an episode of coffee ground emesis, which was reported to the physician and resulted in orders to send the resident to the hospital. The medical record did not contain evidence that the resident and/or representative received the required discharge notice or a bed hold policy with rates and bed hold days, and the SSD confirmed this during interview. The facility’s Transfer and Discharge Policy and Procedure stated residents have a right to remain in the facility unless conditions for transfer or discharge are met.
Meals Not Served in Accordance With Ordered Double Portions
Penalty
Summary
The facility failed to ensure that meals were served in a form designed to meet individual resident needs for two residents reviewed for food service. Resident #24 had diagnoses including chronic obstructive pulmonary disease, bipolar disorder, and alcohol dependence, and his MDS indicated intact cognition. His physician order specified a regular diet with regular texture, regular consistency, and double portions for meals. The resident’s meal ticket also reflected preferences including juice, hot cereal, no pasta, and double portions for all meals. However, the resident stated he did not routinely receive double portions, and observation of his lunch tray showed an Italian sausage link, scalloped potatoes, and lima beans without double portions. The DON confirmed that Resident #24 did not receive double portions for the lunch meal. Resident #35 had diagnoses including bipolar disorder, essential hypertension, and diabetes, and the MDS indicated his memory was okay. His physician order specified a regular diet with regular texture, thin liquids, and double portions. During observation, the resident stated the facility did not provide double portions and that food was a big thing. His lunch tray was observed to contain a hamburger, potato salad, peas/carrots, and pudding, and later another lunch tray contained one Italian sausage link, scalloped potatoes, and lima beans, again without double portions. CNA #848 confirmed the resident did not receive double portions per the meal ticket, and the DON confirmed the findings.
Menu Not Followed and Substitution Log Missing
Penalty
Summary
The facility failed to follow the weekly menu and maintain a substitution log for meals served to residents. Review of the weekly menu for 05/03/26 to 05/09/26 showed specific planned entree and side item choices for supper and lunch, but observations on 05/06/26 and 05/07/26 showed different meals being served than those listed on the menu. On 05/06/26, the planned supper options were jerk chicken sandwich or grilled ham and cheese sandwich with buttered carrots and frosted spice cake, but the tray line served a hamburger with shredded lettuce and tomato, french fries, and chocolate frosted spice cake. The Regional Kitchen Director stated the carrots were substituted for french fries because the lettuce and tomato on the hamburger were considered the vegetable, and he said the hamburger was an option on the spreadsheet menu. On 05/07/26, the planned lunch menu listed turkey meatloaf or a BBQ rib patty with mashed potatoes, gravy, brussels sprouts, fruit mix, and cornbread, but the meal observed was a BBQ rib patty with stuffing, mashed potatoes, mixed vegetables, fruit, and a sugar cookie. The Kitchen Director stated many substitutions were being made because the freezer was broken and certain items could not be stored. The Regional Kitchen Director could not find the substitution log and said he would start a new one. Later that day, the planned supper menu listed Italian parmesan breaded pork cutlet or tuna melt with garlic broccoli and a peanut butter bar, but residents were served ham and cheese sandwiches, stuffing, green beans, corn, and a sugar cookie. The Kitchen Director stated he did not have a freezer to store the pork and that residents do not like pork.
Failure to Provide and Document Restorative Nursing Services per Care Plans
Penalty
Summary
The facility failed to provide restorative nursing services as outlined in the care plans for four residents who were at risk for decline in range of motion (ROM), mobility, and activities of daily living (ADL) performance. Each resident had individualized care plans and therapy discharge recommendations specifying daily restorative interventions such as ambulation with assistive devices, active and passive ROM exercises, and support with ADLs. Despite these documented interventions, point of care documentation revealed frequent omissions, with services marked as not applicable (N/A) or left blank on multiple days and shifts for all four residents. Interviews with staff, including CNAs and facility leadership, confirmed that restorative services were inconsistently provided. One CNA reported not performing restorative services due to a lack of knowledge and stated that there was no designated restorative aide. The Corporate Mobile DON and Regional Director of Clinical Services acknowledged ongoing inconsistencies in the provision and documentation of restorative care, attributing some of the lapses to agency staff, who were nonetheless expected to follow the care plans. Residents also reported that restorative exercises were not being performed as intended. The affected residents had significant medical histories, including Parkinson's disease, major depressive disorder, chronic obstructive pulmonary disease, muscle wasting, Alzheimer's disease, and dementia. Their care plans were designed to maintain or improve their functional abilities and prevent further decline. However, the facility's failure to consistently implement and document restorative nursing interventions as required by the care plans resulted in a deficiency affecting multiple residents.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of abuse in a timely manner for a resident with multiple psychiatric diagnoses, including major depressive disorder, paranoid personality disorder, mild cognitive impairment, and delusional disorder. The resident, who had a history of self-harm and psychiatric conditions, accused a registered nurse of being a murderer and an abuser, as documented in a progress note. This allegation was not reported immediately as required by facility policy. The facility only became aware of the allegation several days later, after discovering the note in the resident's medical record. By that time, the resident had been hospitalized following an intentional ingestion of drain cleaner, reportedly due to feeling overwhelmed and abused at the facility. The registered nurse involved did not report the resident's comment, stating that such remarks were common from the resident. The facility's policy required timely reporting of all alleged violations, but this was not followed in this instance.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to ensure that pain medication was available for a resident, leading to a deficiency in pharmaceutical services. Resident #39, who was admitted with multiple diagnoses including diabetes mellitus, anxiety disorder, and stage three kidney failure, had a physician's order for Lyrica to manage pain. However, upon admission, the resident missed three scheduled doses of Lyrica because the medication was not available. The Medication Administration Record (MAR) indicated that the resident did not receive Lyrica until two days after admission, causing distress to the resident. Interviews with staff and the resident confirmed the unavailability of Lyrica and the resident's dissatisfaction with the situation. The LPN acknowledged the missed doses and the resident's upset state, while the administrator confirmed communication with the physician to expedite the prescription. The pharmacist verified that the order was received and the medication was delivered after the delay. This deficiency was identified during an investigation under a specific complaint number.
Failure to Ensure Proper Respiratory Care and Schedule Diagnostic Test
Penalty
Summary
The facility failed to ensure that a resident had physician orders for BiPAP and did not schedule a diagnostic test for obstructive sleep apnea. The resident, who had diagnoses including obstructive sleep apnea, bipolar disorder, and major depressive disorder, did not have documented oxygen saturations checked from February 20, 2024, through May 1, 2024. Despite a care conference on February 22, 2024, where the use of CPAP was discussed and approved by the Medical Director, there were no subsequent physician orders for BiPAP or CPAP, and the ordered sleep study was not scheduled. Observations revealed that the resident had CPAP and BiPAP supplies in her room, but the Assistant Director of Nursing was unaware of their presence or necessity. Interviews with the Medical Director and the resident's power of attorney confirmed that the resident had been using BiPAP for many years and required it for proper sleep. However, the resident had not used BiPAP since being admitted to the skilled nursing facility, and the sleep study ordered on March 6, 2024, was never scheduled. The facility's policy on CPAP and BiPAP support was not followed, as evidenced by the lack of physician orders and the failure to schedule the sleep study. The Medical Director admitted to not writing orders for BiPAP and stated that the sleep study was deemed unnecessary only because it was never scheduled. The Social Services Designee and Assistant Director of Nursing were both unaware of the need to schedule the sleep study, leading to a lapse in the resident's respiratory care.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to ensure a complete and thorough investigation was conducted for an allegation of neglect/mistreatment/abuse involving a resident. Resident #21, who had a medical history including COPD, atherosclerotic heart disease, chronic atrial fibrillation, hypertension, and hyperlipidemia, alleged that a State Tested Nursing Assistant (STNA) had hit him in the left shoulder. Although the resident did not believe the STNA intended harm and felt it was a joke, the facility's investigation was found to be incomplete. The investigation lacked documentation of which residents were interviewed and when, as well as which staff members were interviewed and when. Only a single witness statement from the Social Services Director was documented, and the Director of Nursing confirmed the lack of thorough documentation. The facility's undated Abuse Prohibition Policy and Procedure mandates that suspected or substantial cases of abuse, neglect, misappropriation of property, or mistreatment be thoroughly investigated, documented, and reported. However, the facility's investigation into the incident involving Resident #21 did not meet these requirements. This deficiency was identified during the investigation of Master Complaint Number OH00151845 and Complaint Number OH00151430, affecting the quality of care and safety assurance for the residents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,122 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — 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.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hudson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Of Hudson | 0.5 mi | ★★★★★ | 0 | 0 |
| Crown Center At Laurel Lake | 1.3 mi | ★★★★★ | 3 | 0 |
| Seasons Nursing And Rehab | 2.1 mi | ★★★★★ | 18 | 0 |
| Wayside Farm Inc | 2.8 mi | ★★★★★ | 0 | 0 |
| Hudson Springs Nursing And Rehab | 3.6 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.