Inspection·June 18, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview the facility failed to ensure resident pain medication was available for administration. This affected one (Resident #39) of three residents reviewed for pain management. The facility census was 38. Findings include: Review of the medical record for Resident #39 revealed an admission date of 05/17/24 at 11:00 A.M. with diagnoses including diabetes mellitus, anxiety disorder, insomnia, hypertensive kidney disease with stage three kidney failure, heart arrhythmia, pneumonia, adult failure to thrive, prostatic hypertrophy, and a history of transient ischemic attack and cerebral infarction (stroke). Review of the physician's orders for Resident #39 revealed an order dated 05/17/24 to administer Lyrica 25 milligrams (mg) in the morning and Lyrica 50 mg orally at bedtime for pain. Review of the Medication Administration Record (MAR) for Resident #39 dated May 2024 revealed the resident missed the following doses of Lyrica due to the medication was not available to be administered: 05/17/24 at 7:00 P.M., 05/18/24 at 7:00 A.M., 05/18/24 at 7:00 P.M. Further review of the MAR revealed Resident #39 did not receive his first dose of Lyrica until 05/19/24 at 7:00 A.M. Interview on 06/13/24 at 7:51 A.M. with Licensed Practical Nurse (LPN) #40 confirmed Resident #39 did not receive the first three scheduled doses of Lyrica upon his admission because the medication wasn't available. LPN #40 confirmed Resident #39 was very upset that he missed doses of Lyrica on the following dates: 05/17/24 at 7:00 P.M., 05/18/24 at 7:00 A.M., 05/18/24 at 7:00 P.M. LPN #40 confirmed the physician needed to transmit a prescription to the pharmacy before they would deliver the medication. She had notified the physician, but the medication wasn't available for administration. Interview on 06/13/24 at 8:06 A.M. with Resident #39 confirmed when he was first admitted the facility was unable to obtain his Lyrica to treat his leg pain and he had been very upset with the situation. Resident #39 stated the facility did administer Tylenol, but it wasn't as effective as the Lyrica medication. Interview on 06/17/24 at 3:10 P.M. with the Administrator confirmed she had received a message from LPN #40 on 05/18/24 that Resident #39 was threatening to leave against medical advice because he had not received his Lyrica. The Administrator confirmed she sent a text message to the physician and the physician responded immediately and sent a text message that she would send an order for the Lyrica via facsimile to the pharmacy. (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 2 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 06/18/2024 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)