Hudson Memorial Nursing Home
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
involved in the incident and re-educate her on correct medication administration. The MDS Coordinator stated that the nurse was instructed that no matter what form medications were given in that she must stay with the resident to ensure the medication was taken before leaving the resident. The MDS Coordinator indicated no other staff were in-serviced regarding the incident and the in-service was just with LPN #1.
During an interview on 11/07/2025 at 12:05 PM CNA #4 indicated that on the 3-11 shift of 10/23/25, she was the CNA caring for Resident #1. CNA #4 stated that she was assisting residents to go to the dining room for supper and noted Resident #1 drinking a supplement that she had never seen her drink before and spitting some of it out. CNA #4 stated she gave Resident #1 something to spit into and she saw crumbles that looked like medication. CNA #4 stated she and another aide took the drink from Resident #1 and took it to the RN Supervisor.
During an interview on 11/7/2025 at 3:05 PM, the DON confirmed that she had been notified by the RN Supervisor on October 23, 2025, that Resident #1 had picked up another resident's medications and taken (consumed) them. The DON indicated she spoke to LPN #1, who was the nurse responsible for giving the medications. The DON indicated LPN #1 told her that once it was realized Resident #1 had drank the supplements belonging to two other residents, the supplements were taken from the resident, who had not drank all the supplement. The DON indicated she verbally instructed LPN #1 that she should not leave a resident until they had taken all their medication and if she was going to crush the medication and put it in a liquid supplement that she should not put it in the full amount of the supplement, but put some of the supplement in a cup, add the medication and observe the resident until all the medication was taken. The DON indicated the APRN was contacted, and staff were instructed to monitor the resident. The DON confirmed that LPN #1 was given a written warning on 10/24/25 for not observing the residents until they took their medications and a written re-education on medication administration.
During an interview on 11/07/2025 at 3:55 PM, the APRN confirmed that on October 23, 2025, she was contacted and notified that Resident #1 had drank someone else's supplements containing medications.
The APRN indicated she first determined that the resident did not have any allergies to the medications.
The APRN indicated her concern was that the resident might become drowsy because of the antidepressant and she ordered the staff to monitor the resident and let her know of any changes. The APRN indicated that she believed any effects the resident might have from the medications would not last more than 4-6 hours. The APRN stated she was not informed after that of any change in the resident condition.
During an interview on 11/07/2025 at 5:10 PM, the Administrator indicated she was informed by the DON
on October 23, 2025, that Resident #1 had taken two separate drinks with other resident's medications in them. The Administrator indicated the nurse responsible was given a written warning and retrained on medication administration.
Review of the policy titled, Medication Administration - General Guidelines with a revision date of November 2011 indicated, medications are administered as prescribed in accordance with good nursing principles including following the five rights for medication administration of right patient, right dose, right medication, right time and right route. Residents are identified before medication administration and observed after to ensure doses are completely taken.
FORM CMS-2567 (02/99) Previous Versions Obsolete
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Hudson Memorial Nursing Home in EL DORADO, AR inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EL DORADO, AR, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Hudson Memorial Nursing Home or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.