Eddy Village Green at Beverwyck

Inspectors wroteBased on observation, record review and interviews conducted during survey, the facility failed to ensure residents were free from neglect and abuse for two (2) (Resident#7 and Resident #26) of seven (7) residents reviewed for abuse and neglect. Specifically, (a) on 07/21/2025, Resident #7 Comprehensive Care Plan intervention to take resident to the bathroom immediately after dinner due to resident's high risk for fall was not implemented and Resident #7 sustained a fall with injury (an abrasion to the left lateral knee area and a bruise to their left inner thigh), and (b) on 05/11/2025, Resident #26's hipsters (pants with padded hips to help decrease the chances of injury) which were a care planned intervention to be placed on the resident daily, were not put on Resident #26 and Resident #26 fell from their wheelchair. [...]

Inspectors wroteBased on record review, observations, and interviews during the survey, the facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in the Main Kitchen and in the house kitchens for House 21 and House 31. Specifically, proper labeling/dating of open items was not followed, and expired food items were found stored ready for use in the refrigerators and freezers.

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to report all alleged violations involving abuse, neglect, and injuries of unknown source immediately, but not later than two (2) hours after the allegation was made, to the administrator of the facility and to other officials (including to the State Agency) for two (2) (Resident #s 12 and 27) of five (5) residents reviewed. Specifically, (a) Resident # 12 reported an incident with alleged abuse on 01/05/2026 at 9:00 PM. This incident was reported to the Department of Health on 01/06/2026 at 9:59 AM. (b) Resident # 27 reported an incident with alleged abuse on 03/30/2025 at 10:09 AM, which was reported to the Department of Health on 03/30/2024 at 6:42 PM. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure that each resident had a person-centered individualized care plan developed and implemented according to professional standards of practice for two (2) (Resident #'s 4 and 22) of 17 residents reviewed. Specifically, (a) for Resident #4, their medicated dandruff shampoo was not noted to be required in the resident's Comprehensive Care Plan; and (b) for Resident #22, the Comprehensive Care Plan did not address the resident's difficulty with speaking. Findings Include: [...]

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure that it maintained acceptable parameters of nutritional status, provided nutrition care and services to each resident consistent with the resident's comprehensive assessment, recognized, evaluated, and addressed the needs of every resident for three (3) (Resident #s 12, 20, and 22) of three (3) residents reviewed for nutrition/hydration status maintenance. Specifically, Residents #s 12, 20, and 22 had significant weight changes that were not assessed timely.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice. This was evident for 2 (House #s 21 and 31) of 2 Houses reviewed. Specifically, 1) the medication carts in House 31 contained an expired stock medication, 2) the medication carts in House #31 contained 3 insulin pens not labeled with the dates opened and the expiration dates after opening, 3) the medication carts in House #'s 21 and 31 contained 2 bottles of eye drops and 2 bottles of nasal sprays not labeled with the dates they were opened and the expiration dates after opening, and 4) the medication cart in House #31 contained an inhaler not labeled with the date opened, and the expiration date after opening. This was evidenced by: [...]

Inspectors wroteBased on observation, staff interviews, and record review during the recertification survey from 11/28/2023 to 12/01/2023, the facility did not ensure food was stored in accordance with professional standards for food service safety for two (2) of 2 resident central kitchens. Specifically, bulk food items and outside items were (A) not labeled for their contents, (B) not date-labeled after open or labeled with an expiry date, (C) and were not discarded by the best use date to discard food items. This was evidenced by: House # 31 During observations on 11/30/2023 from 10:35 AM to 11:26 AM, the following was noted within the main kitchen area for House # 31: A) Eleven (11) items did not have labels describing what they were: [...]

Inspectors wroteBased on record review and interviews during the recertification survey from 11/28/2023 to 12/01/2023, the facility did not ensure they were in compliance with all regulatory requirements when they chose to ask residents or their representatives to enter into an agreement for binding arbitration for 3 (Resident #'s 1, 3, and 5) of 4 residents reviewed for binding arbitration. Specifically, the facility binding arbitration agreement (A) for Resident #1 did not explicitly grant the resident or their representative the right to rescind the agreement within 30 calendar days of signing it; (B) for Resident #3 did not explicitly state that neither the resident nor their representative were required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility, and; [...]

Inspectors wroteBased on observation, record review, and staff interviews during the recertification survey from 11/28/2023 to 12/01/2023, the facility did not ensure hand hygiene procedures were followed by staff involved in direct resident contact for 2 (House #'s 21 and 31) of 2 houses reviewed for infection control. Specifically, for House #21, the facility did not ensure facility staff performed hand hygiene between doffing (removing) and donning (putting on) gloves while preparing dessert in the kitchen on 11/29/2023. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the recertification survey from 11/28/2023 to 12/1/2023, the facility did not dispose of garbage and refuse properly. This was evident for 4 of 9 trash bins in the trash collection area. Specifically, trash bins located in the trash collection area overflowed with waste and the trash collection area was open. This was evidenced by: During an observation of the trash collection area on 11/30/2023 at 1:05 PM, four (4) trash bins overflowed with waste. Three (3) of the trash bins were not fully covered with trash overflowing the bins, and one (1) trash bin was left uncovered with trash overflowing the bin. The trash collection area to the trash bins had a fenced in area with double swing doors for access, with one door left open and unsecured. [...]

Inspectors wroteBased on record review and interviews during the recertification survey dated from 11/28/2023 to 12/01/2023, the facility did not ensure each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated, or the resident had already been immunized. This was evident for 1 (Resident #5) of 5 residents reviewed for immunizations. Specifically, Resident #5 was not offered a pneumococcal immunization upon admission. This was evidenced by: Resident #5 was admitted to the facility on [DATE] with diagnoses of hypothyroidism, osteoarthritis, and iron deficiency anemia. The Minimum Data Set (an assessment tool) dated 10/04/2023 documented the resident was able to make themselves understood, able to understand others, was cognitively intact. The Minimum Data Set documented the resident's pneumococcal immunization status was not up to date / not received. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey from 11/28/2023 through 12/2/2023, the facility did not ensure comprehensive person-centered care plans were implemented. This was evident for 1 (Resident #7) of 12 residents reviewed for Comprehensive Care Plans. Specifically, Resident #7 was found alone on the floor in the bathroom with a skin tear on their right forearm, and their safety awareness care plan documented staff were not to leave the resident alone in the bathroom. This is evidenced by: The policy and procedure titled Falls Management Policy and revised 12/2022 documented the facility would prevent and/or reduce the number of falls by providing an individualized, person-centered care approach with managing fall risk through the process of assessment, planning, implementation, and evaluation. [...]