Inspection·July 25, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to provide a secured and locked location for Resident #9 to store medications for self-administration. This affected one of one resident who self administered medications. The census was 28. Findings include: Review of the medical record for Resident #9 revealed an admission date of 11/28/22 with diagnoses of depression, generalized anxiety disorder, alcohol induced pancreatitis, alcohol abuse and limitation of activities due to disability. Review of the Self-Administration Skills assessment dated [DATE] revealed Resident #9 could correctly secure medications. Review of the nursing note dated 06/23/23 revealed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) spoke with Physician #10 and agreed that Resident #9 was able to self-administer his own medications and that his orders in the electronic medical record would now reflect self-administering of his medications. The nurse was aware of this, and he had been given all his medications. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #9 was cognitively intact, independent with transfers, dressing, toilet use and personal hygiene. Review of the physician orders from July 2023 revealed Resident #9 was ordered the following medication for self-administration: Folic Acid (a vitamin) 1 milligram (mg) by mouth one time a day, Magnesium Oxide (a nutritional supplement) 400 mg by mouth one time a day, multivitamin tablet by mouth once a day, Methocarbamol 500 mg tablet (a muscle relaxant) give 1000 mg by mouth three times a day, Oxybutynin Chloride 5 mg tablet (a bladder relaxant) by mouth one time a day, Carvedilol 12.5 mg tablet (used to treat high blood pressure and heart failure) by mouth every morning and at bedtime, Finasteride 5 mg tablet (used to treat urinary retention) by mouth one time a day, Meloxicam 15 mg tablet (an anti-inflammatory medication) by mouth in the morning, Paroxetine 40 mg tablet (an antidepressant medication) by mouth in the morning, Tamsulosin HCl 0.4 mg tablet (used to treat urinary retention) by mouth two times a day, Trazadone HCl 100 mg tablet (an antidepressant medication) by mouth at bedtime, Buspirone HCl 30 mg tablet (used to treat anxiety) by mouth two times a day, and Omeprazole 40 mg one capsule (treats stomach problems) by mouth one time a day. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 365874 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hudson Elms Nursing Center 563 W Streetsboro Road Hudson, OH 44236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)