The resident had never received medications before admission to the facility. Within hours, nurses began giving 20-milligram doses of morphine sulfate every four hours around the clock.
Licensed Practical Nurse #2 worked the overnight shift starting October 8, 2025, and gave the first dose at 2:00 AM on October 9. They administered another 20 milligrams at 6:00 AM. "They assumed the order was correct and did not question the dosage of morphine sulfate because the resident was on hospice," inspectors wrote.
The day shift nurse also found the dose troubling but gave it anyway. Licensed Practical Nurse #1 told inspectors "the dose seemed excessive, however because Resident #1 was on hospice, they did not question it prior to giving the medication." They administered the third 20-milligram dose at 2:00 PM.
Only after giving that second dose on their shift did Licensed Practical Nurse #1 raise concerns with the supervising registered nurse.
Registered Nurse #4 told inspectors that around 3:45 PM on October 9, when they left for the day, "Resident #1 was stable and because Resident #1 was a hospice patient, the goal was to be comfortable, which they believed the resident to be."
The resident's health care proxy had left the facility around 2:00 PM on October 8 and returned around 4:00 PM the next day to find their loved one unresponsive. "Resident #1 was sleeping soundly enough to be snoring and they were unable to wake them," the proxy told inspectors.
When the proxy asked unnamed staff if the resident had been like that all day, staff reportedly said yes.
An unnamed doctor spoke with the health care proxy and mentioned the resident had received morphine, calling it "a low dose." The doctor said Narcan - the overdose reversal medication - "was not safe to use" and advised the proxy "to let Resident #1 sleep it off."
The proxy left after 7:00 PM on October 9.
They received a call at 4:00 AM summoning them back to the facility because the resident was dying. Upon arrival, the proxy again asked if the resident should receive Narcan. Facility staff told them "Narcan would be ineffective at that time."
The inspection found nurses failed to question medication orders despite recognizing potential problems, violating federal requirements for proper medication administration and resident safety.
Both nurses who administered the morphine told inspectors they didn't question the dosage specifically because the patient was on hospice care. Their assumption that excessive pain medication doses were appropriate for dying patients led them to override their professional judgment about what constituted safe dosing.
The facility is disputing the citation, which federal inspectors classified as causing minimal harm or potential for actual harm to few residents.
The case illustrates how end-of-life care assumptions can override basic medication safety protocols. Three doses of 20 milligrams each - totaling 60 milligrams over 14 hours - rendered the resident completely unresponsive within hours of the final administration.
The health care proxy's repeated questions about Narcan suggest family members recognized signs of potential overdose that medical staff dismissed as appropriate comfort care. The unnamed doctor's characterization of 60 milligrams as "a low dose" conflicts with the nurses' own assessment that the amount seemed excessive.
Federal inspectors completed their investigation on November 26, 2025, following the complaint that prompted the review.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Eddy Heritage House Nursing and Rehabilitation Ctr from 2025-11-26 including all violations, facility responses, and corrective action plans.