Hudson Memorial: Accident Hazard Violations - AR
CNA #4 was helping residents get to the dining room for supper on October 23 when she noticed Resident #1 drinking a supplement she had never seen her consume before. The resident was spitting some of it out.
The nursing assistant gave Resident #1 something to spit into and saw crumbles that looked like medication. She and another aide took the drink away from the resident and brought it to the RN Supervisor.
The incident occurred because LPN #1 had crushed medications and mixed them into full supplement bottles, then left the residents unattended before confirming they had consumed their medications completely.
The Director of Nursing confirmed she was notified by the RN Supervisor that evening that Resident #1 had picked up and consumed medications belonging to other residents. When she spoke to LPN #1, the nurse told her that once staff realized what happened, they took the supplements away from Resident #1, who had not finished drinking them.
The DON instructed LPN #1 that she should never leave a resident until they had taken all their medication. If crushing medications and mixing them into liquid supplements, she should put only some supplement in a cup, add the medication, and observe the resident until everything was consumed.
The facility's Advanced Practice Registered Nurse was contacted about the incident. She first determined that Resident #1 had no allergies to the medications she had accidentally consumed.
Her primary concern was that the resident might become drowsy from an antidepressant that was among the medications. She ordered staff to monitor the resident and report any changes in condition.
The APRN believed any effects from the medications would last no more than four to six hours. She stated she received no reports of changes in the resident's condition afterward.
LPN #1 received a written warning on October 24 for failing to observe residents until they took their medications. She also received written re-education on proper medication administration procedures.
The Administrator confirmed she was informed by the DON on October 23 that Resident #1 had consumed two separate drinks containing other residents' medications.
According to the facility's medication administration policy, medications must be given following the five rights of medication administration: right patient, right dose, right medication, right time and right route. The policy requires that residents be identified before medication administration and observed afterward to ensure doses are completely taken.
The MDS Coordinator stated that LPN #1 was instructed that regardless of what form medications are given in, she must stay with the resident to ensure the medication is taken before leaving them. Only LPN #1 received in-service training regarding the incident.
Federal inspectors found the facility failed to ensure medications were administered according to physician orders and accepted professional standards. The violation was classified as causing minimal harm or potential for actual harm to few residents.
The inspection revealed a breakdown in basic medication safety protocols when a nurse left crushed medications mixed in full supplement containers, creating conditions where residents could easily consume the wrong medications. The incident demonstrated how medication errors can occur when staff fail to follow established procedures for ensuring patients consume only their prescribed medications under direct observation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hudson Memorial Nursing Home from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Hudson Memorial Nursing Home in EL DORADO, AR was cited for violations during a health inspection on November 20, 2025.
The resident was spitting some of it out.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.