Eddy Heritage House Nursing and Rehabilitation Ctr

Inspectors wroteBased on observations, interviews, and record reviews conducted during the abbreviated survey (#2665815), the facility failed to ensure residents' right to be free from neglect for one (1) of five (5) residents reviewed. (Resident #1). Specifically, on [DATE] at 2:00 PM, the facility identified that Resident #1 received four (4) incorrect doses of morphine sulfate (a strong opioid analgesic used to treat moderate to severe pain) totaling 80 milligrams over a 12-hour timeframe. This resulted in the resident becoming lethargic and unresponsive with unstable vital signs including blood pressure and oxygen saturation. The facility failed to provide interventions to reverse the effects of the medication despite the family inquiry to Narcan (also known as naloxone, a medication used to reverse or reduce the effects of opioids). The resident expired on [DATE] at 6:20 AM. [...]

Inspectors wroteBased on record reviews and interviews conducted during the abbreviated survey (#2665815), the facility failed to ensure residents were free from significant medication errors for one (1) of five (5) residents reviewed (Resident #1). Specifically, the facility administered four (4) incorrect doses of morphine sulfate (a strong opioid analgesic used to treat moderate to severe pain), totaling 80 milligrams over a 12-hour period. This resulted in Substandard Quality of Care that was Immediate Jeopardy and resulted in the death of Resident #1, with the likelihood of serious injury, harm, impairment, or death to all 108 residents in the facility. This is evidenced by:Cross reference to F-600: Free from Abuse and Neglect. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an abbreviated survey (Case #2665815), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for four (4) (Resident #'s 10, 11, 12, and 13) of four (4) residents reviewed for medication administration. Specifically, the resident's medications were administered late across various units and their medical providers were not notified. This is evidenced by: The Facility Policy titled Medication Administration effective date 12/21/2025, documented it was the policy of the facility that each patient/resident/elder would receive medications according to provider orders and accepted professional standards. [...]

Inspectors wroteBased on record reviews and interviews conducted during the abbreviated survey (Case #2665815), the facility did not ensure equal access to quality care regardless of diagnosis for (1) (Resident #1) of one (1) resident reviewed. Specifically, staff did not question, assess, or respond to a significant medication error because Resident #1 was receiving hospice services. Licensed Practical Nurse #2 stated they did not question medication that they dispensed to Resident #1 because the resident was on hospice. This compromised Resident #1's right to dignity, self-determination, and access to medically appropriate care. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. [...]

Inspectors wroteBased on interviews and record review conducted during the abbreviated survey (Complaint #2665818), the facility did not ensure that hospice or the resident representative/emergency contact was notified of a significant medication error for 1 (one) (Resident #1) of 5 (five) residents reviewed. Specifically, Resident #1 experienced a significant medication error on 10/09/2025, and there was no documented evidence that hospice was notified, and the resident's representative was not made aware until 10/28/2025. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. [...]

Inspectors wroteBased on interviews and record review conducted during an abbreviated survey (Case #2665815), the facility did not ensure that all alleged violations involving neglect were reported immediately, but not later than 2 (two) hours after the allegation was made, if the event that caused the allegation resulted in serious bodily injury to the Administrator and to the State Survey Agency in accordance with State Law for one (1) (Resident #1) of 1 resident reviewed. Specifically, Resident #1 was involved in a serious adverse event / medication error that resulted in their death on [DATE]. The event was not reported to the New York State Department of Health. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the abbreviated survey (Case # 2665815) from 11/17/2025 to 11/26/2025, for 1 (one) (Resident #1) of 3 (three) residents reviewed, the facility did not ensure that the Physician provided supervision of medical care. Specifically, Physician #1 signed 5 incorrect orders for morphine concentrate oral liquid resulting in Resident #1 receiving 80 milligrams of morphine over a 12-hour period. Additionally, there was no documented evidence that Physician #1 provided any follow up instructions or care to Resident #1 after the medication administration was discovered. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the abbreviated survey (Case # 2668815), the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 1 (one) of 5 (five) residents reviewed (Resident #1). Specifically, the facility administered morphine sulfate (strong opioid used to treat moderate to severe pain) as a routine, standing medication despite no documented clinical evidence of pain or shortness or breath, exposing Resident #1 to unnecessary risk of adverse drug effects including over-sedation and respiratory depression. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. [...]

Inspectors wroteBased on record reviews and interviews conducted during the abbreviated survey (Case # 2665815), the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of ar resident (Resident #1). Specifically, the facility lacked oversight in place to use its resources (staff, policies, and communication systems) effectively and efficiently to protect Resident #1. This is evidenced by: Reference is made to deficiencies related to ineffective administration: Please refer to F600 as it pertains to the facility's failure to ensure freedom from neglect. Please refer to F760 as it pertains to the facility's failure to ensure freedom from significant medication errors. Please refer to F550 as it pertains to the facility's failure to ensure resident dignity. [...]

Inspectors wroteBased on interviews and record reviews conducted during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure prompt efforts were made to respond to grievances and complaints from residents of the facility. Specifically, the facility did not ensure the facility's process for missing property and grievances was followed when the residents reported lost items or filed complaints. Additionally, the residents needed to be appropriately apprised of the progress toward any resolutions made for grievances or missing items. This is evidenced by: Policy and Procedure titled Complaints and Grievances, dated 1/2016, documented that the facility would promptly deal with complaints and recommendations made by residents and their designated representatives. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not provide pharmaceutical services including procedures that assured the accurate dispensing and administering of all drugs and biologicals according to professional standards. Specifically, (a.) an administered controlled substance was not signed out on the control substance record when documented in the resident's medical record as administered; and (b.) nursing staff did not verify the correct resident prior to medication administration for 2 (Resident #'s 4 and 76) residents observed for medication administration. This is evidenced by: The facility's Medication Administration Policy and Procedure, effective 12/21/2023, under Procedure: documented the Registered Nurse/Licensed Practical Nurse will 3. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure drugs and biologicals were labelled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) controlled substances were not kept secured in a double locked cabinet; (c.) expired medications were present; and (d.) an unlocked medication cart was left unattended. This was evident for 4 out of 6 medication carts reviewed, and for 1 out of 3 medication storage rooms reviewed. This is evidenced by: The facility's Medication Administration Policy and Procedure, effective 12/21/2023, documented the nurse was to carefully check the name, dose, amount of administration and expiration date, and to remain with the unlocked medication cart/cabinet. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not prepare and serve food in accordance with professional standards for food service safety in 3 (three) of 3 kitchenettes. Specifically, food was not stored to preclude contamination, the kitchenettes were not clean, and the cabinetry in the kitchenettes were not in good repair. This is evidenced by: During observations on 2/20/2024 at 10:44 AM, single-serving packets of beverage thickener were stored under the sink in the Second Floor Unit kitchenette. Cabinets, cupboards, drawers, microwave ovens, and the floor in corners and next to walls were soiled with food particles in the Second Floor Unit kitchenette and the Third Floor Unit kitchenette; [...]

Inspectors wroteBased on observations, interviews, and record review during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure treatment with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality for 2 (Resident #'s 257 and 258) of 22 residents reviewed for privacy and dignity. Specifically, (a.) staff did not knock on Resident #257's door prior to entering and (b.) did not cover the urine collection bag for Resident #258 for treatment reflective of dignified care and respect for the privacy of the residents. This is evidenced by: A. Staff did not knock on resident doors prior to entering: [...]

Inspectors wroteBased on observations, record reviews and interviews conducted during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure the development of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 1 (Resident #70) of 22 residents reviewed for comprehensive care plans. Specifically, for Resident #70, the facility did not ensure a comprehensive care plan was developed to address the medical order for supplemental oxygen use. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure Comprehensive Care Plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for 2 (Resident #'s 47 and #257) of 18 residents reviewed. Specifically, for Resident #47, the comprehensive care plan for psychotropic medication was not reviewed/revised with medication changes. For Resident #257, the comprehensive care plan was not updated/revised after intervention for oxygen administration was discontinued. This is evidenced by: [...]

Inspectors wroteResident #47 Resident #47 was admitted with the diagnoses of dementia, generalized anxiety disorder (ongoing anxiety that interferes with daily activities), and type 2 diabetes. The Minimum Data Set, dated [DATE] documented the resident was able to be understood, could understand others and had a moderate cognitive impairment. Review of Resident #47's medical record indicated a Physician's Order dated 12/15/2023 for quetiapine (psychotropic) 25 milligrams by mouth every 24 hours as needed for psychosis. Record review indicated this order was discontinued on 1/15/2024. Record review indicated Resident #47 had a Physician's Order dated 1/16/2024 for quetiapine 25 milligrams by mouth every 24 hours as needed for psychosis. Record review indicated this order did not include an end date. [...]

Inspectors wroteBased on observation and interviews during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not dispose of garbage and refuse properly. Specifically, the exterior dumpster was not clean nor in good repair, and the grounds around the dumpster was littered. This is evidenced by: During observations on 2/20/2024 at 10:38 AM of the exterior grounds, the side door to the garbage dumpster had a 3-inch round hole, one side of the dumpster was soiled with black drip marks, and the ground around the dumpster was littered with food refuse. During an interview on 2/20/2024 at 10:41 AM, Food and Nutrition Director #1 stated that litter could have been there for 2 days and that they would ask the Manager of Facilities #1 to contact the dumpster vendor for dumpster cleaning and door repair. [...]

Inspectors wroteBased on interview and record review during the recertification and abbreviated survey (Case # NY00297663) from 2/20/2024 to 2/27/2024, the facility did not ensure that a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standard of quality care was developed within 48 hours of admission. This was identified for 1 (Resident #107) of 22 residents reviewed. Specifically, Resident #107 was admitted on [DATE] with history of falls and was assessed to be high risk for falls. A baseline care plan was not developed within 48 hours to include at risk for falls with interventions for safety. This is evidenced by: Cross-reference F-689. The facility's policy and procedure titled Falls Management Policy, effective 10/04/2021, documented Procedure: #2: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00316856), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse, to the Administrator of the facility and to the State Survey Agency for 1 (Resident #1) of 5 residents reviewed. Specifically, an allegation of physical abuse reported by Resident #1 on 5/15/2023 was not reported to the New York State Department of Health after the allegation was made. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia, squamous cell carcinoma (skin cancer), and anemia (condition of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissue). [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #'s NY00310829, NY00311751, NY00316856, and NY00319018), the facility did not ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were thoroughly investigated for 5 (Residents #1, 2, 3, 4, and 5) of 5 residents reviewed. Specifically, the facility did not conduct a thorough investigation when Resident #1 alleged abuse on 5/15/2023 by a Certified Nurse Aide. For Resident #2, the facility did not conduct a thorough investigation to determine the cause of a fracture (bone break) identified on 2/28/2023. For Resident #3, the facility investigation began 5 days after the resident's unwitnessed fall and did not identify the cause or corrective actions to prevent re-occurrence. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #'s NY00311751 and NY00316856), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Residents # 1 and 2) of 5 residents reviewed. Specifically, for Resident #1, the facility did not ensure an immediate and thorough assessment of the resident's injury alleged to be caused by abuse. For Resident #2, the facility did not ensure an assessment of new onset pain resulting in delay of treatment for a fracture (bone break). This is evidenced by: The facility Policy titled Abuse Prevention and Investigation, effective 6/27/2023, documented, when abuse is suspected or alleged, resident safety must be a priority. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not maintain food preparation areas in accordance with professional standards for food service safety. Food preparation and serving areas and equipment are to be kept clean and in good repair. Specifically, equipment in the main kitchen and 2 of 2 unit kitchenettes were not clean or in good repair. This is evidenced as follows. The main kitchen and the kitchenettes were inspected on 09/08/2021 from 9:05 AM through 10:09 AM. In the main kitchen, shelving, the cleaning chemical storage area and door, and the floor under the cafe prep sink were soiled with food particles or dirt. The light shields over the dish washing machine and by the walk-in refrigerator were broken. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, 3 of 3 dumpsters and the surrounding grounds were not maintained in a sanitary condition. This is evidenced as follows. The garbage dumpsters and surrounding area were inspected on 09/08/2021 at 11:01 AM. One of 3 dumpsters, the left most dumpster and outside the caged area for dumpsters, was found to have garbage waste stored within, and the drain hole did not have a plug to prevent pest entry. This dumpster was placed on the earthen ground, and the instructions on the dumpster state Notice, Container Must Be Placed on a Hard Level Surface, Load Uniformly. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that it developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for five Residents (#s 9, 40, 57, 65, & 162) of 24 reviewed. Specifically; the facility did not ensure that Resident #9 had a care plan (CP) to address constipation, that Resident #162 had a CP that addressed diarrhea; that Resident #57's CP for pain and comfort included person-centered interventions for pain management; [...]

Inspectors wroteBased on record review and interview, the facility did not ensure a policy regarding use and storage of foods brought to residents by family and other visitors was developed to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure facility staff would assist dependent residents in accessing and consuming food brought in by family or visitors. This is evidenced by: A Policy and Procedure titled Use and Storage of Food Brought to Residents From Home dated 1/17, did not include documentation regarding how the facility staff would assist dependent residents in accessing and consuming food brought in by family or visitors. During an interview on 8/01/19 at 7:36 AM, the Assistant Director of Dining Services stated he was not aware of policy requirement. 10NYCRR415.14 (h)

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure residents maintained acceptable parameters of nutritional status for 2 (Resident #'s 29 and 84) of 3 residents reviewed for nutrition. Specifically, for Resident #29, the facility did not ensure reweighs were obtained and care plan interventions were revised to address the resident's significant weight loss; and for Resident #84, the facility did not ensure a protein supplement was implemented in a timely manner for the resident's increased protein needs while on dialysis. Resident #29: The resident was admitted to the facility on [DATE], with diagnoses of dysphasia, major depressive disorder, and dementia with behavior disturbance. [...]

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for one (1) resident (Residents #73) of three (3) residents reviewed for respiratory care. Specifically, for Resident #73, the facility did not ensure the resident received the physician ordered liter flow of oxygen (O2) from 7/28/19-7/30/19, did not ensure the resident's change in respiratory status was assessed, and did not ensure the resident's record reflected notification of the practitioner of the need to revise or alter the respiratory care provided. This is evidenced by: [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not maintain equipment in a clean and sanitary manner in accordance with professional standards for food service safety. Food preparation and serving areas are to be kept in good repair, and equipment is to be kept clean. Specially, food and non-food contract surfaces were not kept clean and in good repair; and facial hair was not properly restrained to prevent physical contamination of food. This is evidenced as follows: Finding #1: The main kitchen and kitchenettes were inspected on 07/29/2018 at 8:35 AM. In the main kitchen the meat slicer, can opener, cutting boards, shelves under the food service counters, knife holder by the stovetop, and the floor in the walk-in freezer were soiled with dust, grease, or food particles. [...]