Eddy Heritage House Nursing And Rehabilitation Ctr

During an interview on 11/19/2025 at 11:40 AM, Registered Nurse #4 stated on 10/09/2025 Licensed Practical Nurse #1 informed them that the morphine dosage was likely wrong and they checked it.

Registered Nurse #1 stated they immediately discontinued the order, informed Physician #1 of the error, and received a new correct order for morphine, which was entered into the system.

They further stated, the did not notify Director of Nursing #1 or Administration, contacting the doctor was their first priority.

During an interview on 11/19/2025 at 12: 34 PM, Administrator #1 stated they were not in the facility when the incident occurred.

They had a received a voicemail from the resident representative when they returned to work.

They stated the resident representative had reached out to Director of Nursing #2, but Director of Nursing #2 did not return their call.

Administrator #1 stated they met in person with the family on 10/28/2025.

During an interview on 11/19/2025 at 2:04 PM, Medical Director #1 stated the family was not communicated immediately about the medication error. 10 New York Codes, Rules, and Regulations 415.3(f)(2)(ii)(d)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

SUMMARY STATEMENT OF DEFICIENCIES

(three) resident units, the contact for Community Hospice was visible at accessible locations such as a nursing station.

The facility had 3 (three) residents enrolled in Hospice services on [DATE] and in each of the three resident's electronic medical records and hard(paper) charts, the contact number for Community Hospice was visible and accessible under contacts on the residents' face sheets.

Medication error reporting policy was updated on [DATE] to include a statement that requires the Physician/Nurse Practitioner, upon notification of medication error, to provide direction for monitoring, duration of monitoring and expected follow up communication.

The policy also states that documentation will include nature of the incident, nature of the event, individuals notified (including family and hospice as applicable), actions taken, orders received, results of continued monitoring, assessments and communication.

Completed [DATE].

Observed to be true [DATE], effective date [DATE] by review of the revised policy supplied to surveyors.All on-call Physicians and Nurse Practitioners (for dates [DATE]-[DATE]) were in serviced by the Chief Medical Officer #1 regarding high-risk medications and review of electronic ordering for safe dosing.

The remaining Physicians and Nurse Practitioners were in serviced on [DATE].

All nursing including agency staff will be educated by nursing educator/designee prior to start of shift on the updated Medication Error Reporting policy, which includes directions on provider and family notification as well as resident monitoring and documentation requirements was completed on [DATE].

Education Sign-In Sheets titled Transcription- Triple Check- Medication Reconsolidation, Transfer report - hand off sheet, Neglect related to Resident Monitoring - Education sign-in sheets documented 39 out of 39 in house nurses and 13 agency nurses educated. 13 Agency nurses left to educate if they return to the facility.

During an interview with Director of Nursing #1 on [DATE] at 12:18 PM, surveyor identified 1 (one) in house nurse Registered Nurse #11 was not educated prior to their shift on [DATE] and was actively working on their shift.

Registered Nurse #11 was educated on [DATE] at 12:43 PM.

Compare transcribed orders with original provider order for accuracy.? Checks will be completed and documented in the paper chart for the next two consecutive shifts.? All nursing staff (including agency staff) will receive education by the nurse educator, supervision or designee prior to start of shift regarding medication reconciliation, medication transcription, triple check and safe medication administration practices.

Education sign-in sheets documented 39 out of 39 in house nurses and 13 agency nurses educated. 13 Agency nurses left to educate if they return to the facility.

Education sign in sheet titled, Transcription- triple check-medication reconsolidation, transfer repot- hand off sheet, Neglect related to resident monitoring, documented 39 out of 39 in-house nurses and 13 agency nurses were in-serviced regarding on the abuse/neglect and mistreatment policy with a special focus on potential neglect related to medication errors and lack of monitoring, assessment and documentation related to change in condition.

There are 13 agency nurses left to educate if they return to work at the facility. 10 New York Codes, Rules, and Regulations 415.4(b)(I)(i)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

SUMMARY STATEMENT OF DEFICIENCIES

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.

The Facility Policy titled Medication Errors and Reporting effective [DATE], documented the facility maintained a nonpunitive reporting culture, which encouraged all staff to report medication events immediately.

All events must be documented, investigated and reviewed regularly to improve systems and reduce future errors.

Medication events included transcription errors. It further documented that any reportable error, per New York State (refer to: Reporting Serious Adverse Events to New York State Department of Health Policy) would be escalated to the Medical Director, Director of Nursing, and the Executive Director.

The Facility Policy titled Reporting Serious Adverse Events to NYS DOH effective [DATE], documented the purpose and the scope was to ensure timely and accurate reporting of serious adverse events in compliance with New York Department of Health regulations and federal requirements. It was documented that a medication or treatment error that resulted in harm was considered a reportable serious adverse event and required reporting to the New York State

Resident #1 was admitted on [DATE] for respite care.

The resident received four (4) incorrect doses of morphine sulfate totaling eighty (80) milligrams over a twelve (12) hour period on [DATE].

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.? ? An undated Medication Event Investigation documented, on [DATE] it was discovered that Resident #1's morphine sulfate order had been transcribed in error by milliliters and not milligrams.

The order continued until [DATE] at 2:00 PM, when the medication nurse questioned the order.

There was no documented evidence that the serious adverse event or medication error involving Resident #1 was reported to the New York State Department of Health.

During an interview on [DATE] at 11:20 AM, Administrator #1 stated that they did not feel that Resident #1's passing was caused by the morphine sulfate administration.

They stated Executive Director #1 and Medical Director #1 did not connect the morphine administration to Resident #1's death when Administrator #1 reached out to them regarding the incident.

When asked if Administrator #1 reported incidents to the New York State Department of Health without speaking to Executive Director #1 or Medical Director #1, Administrator #1 stated that in this particular case, they felt like they needed guidance and was advised to not report it.? 10 New York Codes, Rules, and Regulations 483.12 (c) (1)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

SUMMARY STATEMENT OF DEFICIENCIES

Regulations 415.12

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 11/19/2025 at 11:14 AM, Pharmacist Supervisor #1 stated the facility was contacted on 10/08/2025 to clarify an accurate dosage of morphine sulfate for Resident #1 and the dosage was clarified with Registered Nurse #3 on 10/08/2025 at 6:29 PM.? They clarified the order again with Registered Nurse #3 at 7:36 PM.? When a new order was received on 10/09/2025, they clarified the order with Physician #1 at 4:15 PM.

Additionally, there was a request to access the pyxis to obtain Narcan however, according to the records, it was never administered per their records.

Records of all contacts with the facility regarding morphine order clarifications were requested and received. ??

During an interview on 11/19/2025 at 11:54 AM, Physician #1 stated they weren't normally the doctor for respite residents, but they were asked to do Resident #1's orders.

Physician #1 recalled there was an issue with the concentration of the morphine order.

Physician #1 stated that they gave verbal orders for morphine sulfate.

The concentration was 20 milligrams, which was higher than normal.

Physician #1 didn't realize the issue when they put in the order.? Physician #1 stated they did check and sign the order but didn't read it carefully and looked at the milliliter without realizing the concentration would change the dosage.?Physician #1 stated that they should have checked it more carefully.?Physician #1 further stated that they didn't hear from pharmacy at that time about any issues and after Resident #1 passed, Physician #1 wasn't really involved with any investigation, Medical Director #1 would have more information.??

During an interview on 11/19/2025 at 2:04 PM, Medical Director #1 stated that after the incident, they had a conversation with Physician #1 with no additional action.

They stated that it was a significant medication error, but Physician #1 was a good doctor that made a mistake.10 New York Codes, Rules, and Regulations 415.15(b)(1)(i)(ii)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

SUMMARY STATEMENT OF DEFICIENCIES

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

SUMMARY STATEMENT OF DEFICIENCIES

received 20 milligrams of morphine sulfate every four (4) hours for four (4) doses, 80 milligrams total, and they stated it was a significant medication error.

Medical Director #1 stated they had a meeting with the family after the resident expired to discuss what happened.

Medical Director #1 stated that Narcan would not have been effective at 4 AM when the family asked for it.

When asked if Narcan would have been effective at 4 PM when the family asked for it the first time, Medical Director #1 stated that there were some risks in giving Narcan and that because the resident was comfortable and sleeping, the family and Physician #1 decided not to administer Narcan to Resident #1.The facility was notified of the Immediate Jeopardy on [DATE] at 5:28 PM.

The facility's Immediate Jeopardy Removal Plan dated [DATE] at 10:20 PM was accepted.

The Immediate Jeopardy was removed on [DATE] at 2:47 PM. *****************Based on observations, interviews and record review conducted on [DATE], [DATE], [DATE], and [DATE], the facility's corrective actions were fully implemented effective [DATE] at 2:47 PM and included the following: 35 narcotic orders were reviewed for ongoing appropriateness and safety by Medical Director #1 on [DATE]. No corrections were required. 51 narcotic orders were reviewed for ongoing appropriateness and safety on [DATE].

One (1) order of four (4) written by Physician #1 was found to have an error that could have negatively impacted a Resident.

Immediate education was provided to Physician #1 and Licensed Practical Nurse #1, and the order was amended by Chief Nursing Officer #1 and Medical Director #1 immediately.

All active medication orders were reviewed between [DATE] and [DATE] by the consultant pharmacists and medical director for ongoing appropriateness and safety.

Administrator #1 worked with electronic ordering system creators to enable a feature to run reports that reflected ordering errors for closer daily monitoring.

All on-call physicians and nurse practitioners (for dates [DATE] -[DATE]) were in serviced by the Medical Director #1 regarding high-risk medications and review of electronic ordering for safe dosing.

The remaining physicians and nurse practitioners were inserviced on [DATE]. ‘Transcription of Orders' policy was developed on [DATE] to include information regarding medication reconciliation as well as the triple check process.

Compared transcribed orders with original provider order for accuracy.

Checks were completed and documented in the paper chart for the next two (2) consecutive shifts.

All nursing including agency staff will be educated by nursing educator/designee prior to start of shift on the updated Medication Error Reporting policy, which includes directions on provider and family notification as well as resident monitoring and documentation requirements was completed on [DATE].

Education Sign-In Sheets titled Transcription- Triple Check- Medication Reconsolidation, Transfer report - hand off sheet, Neglect related to Resident Monitoring - Education sign-in sheets documented 39 out of 39 in house nurses and 13 agency nurses educated. 13 Agency nurses left to educate if they return to the facility.

Record review completed on [DATE] at 5:20 PM, documented a verbal order was entered directly into the electronic medical record. No order was placed in the chart for nursing staff to start the triple check process.

During an interview on [DATE] at 5:45 PM, Chief Nursing Officer #1 stated that the medication nurse was educated on [DATE] around 5:30 PM regarding an end date needed for the order and printing orders to place in the chart to begin the triple check process.

They further stated that Medical Director #1, and/or Administrator #1 and/or Chief Nursing Officer #1 would check orders from the previous day starting on [DATE].

They stated Nurse Managers were responsible for completing audits on triple check and would bring audit results to Quality Assurance monthly meetings. On [DATE] at 2:47 PM, surveyors verified the facility conducted a daily 24-hour look back on all new medication orders by Director of Nursing #1 or designee.

Interviews with all parties responsible for these barrier checks showed they were aware of their required responsibilities. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

SUMMARY STATEMENT OF DEFICIENCIES

Based 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 F-F600 as it pertains to the facility's failure to ensure freedom from neglect.

Please refer to F-F760 as it pertains to the facility's failure to ensure freedom from significant medication errors.

Please refer to F-F550 as it pertains to the facility's failure to ensure resident dignity.

Please refer to F-F609 as it pertains to the facility's failure to ensure adverse events were reported to the State Survey Agency.

Please refer to F-F684 as it pertains to the facility's failure to ensure services provided met professional standards.

Please refer to F-F757 as it pertains to the facility's failure to ensure each resident's drug regimen was free from unnecessary medications without adequate indications.

Please refer to F-F841 as it pertains to the facility's failure to ensure the responsibilities of the Medical Director were completed and accurate.

Please refer to F-F710 as it pertains to the facility's failure to ensure that resident's care was supervised by a Physician.

Facility administration leadership failed to provide effective oversight, policy enforcement, and resource allocation to ensure resident safety, resulting in Neglect (F-F600) and a Significant Medication Error (F-F760) that contributed to the death of Resident #1.

These deficiencies collectively reflect ineffective facility administration and failure to ensure systems were in place to protect resident safety.

During an interview on 11/19/2025 at 10:05 AM, Director of Nursing #2 stated they were largely unaware of the circumstances surrounding Resident #1's decline and did not recall being notified at the time of the resident's passing.

During an interview on 11/19/2025 at 12:08 PM, Director of Nursing #1 stated that they were not directly involved in the incident investigation and were unaware of any systematic changes implemented following the medication error.

They further stated that there was a triple check system that was used to ensure errors like what had occurred didn't happen, and it was in place prior to the incident.

During an Interview on 11/19/2025 at 12:34 PM, Administrator #1 stated the medication transcription error could be attributed to confusing hospice orders and staff overstimulation, and stated hat leadership reviewed errors after the incident.

They stated as a result of the incident, staff looked at all the errors beginning with those that came from the hospital.

They stated Morphine Sulfate transcription error began as a scheduled dose when it should have been written as needed During an interview on 11/19/2025 at 2:04 PM, Medical Director #1 stated the event was a significant medication error and that family communication occurred at a later date.

During an interview on 11/26/2025 at 11:20 AM, Administrator #1 stated that they did not feel that Resident #1's passing was caused by the morphine sulfate administration.

They stated Executive Director #1 and Medical Director #1 did not connect the morphine administration to Resident #1's death when Administrator #1 reached out to them regarding the incident.

When asked if Administrator #1 reported incidents to the New York State Department of Health without speaking to Executive Director #1 or Medical Director #1, Administrator #1 stated that in this particular case, they felt like they needed guidance and was advised to not report it.? 10 New York Codes, Rules, and Regulations 483.70(i)

Facility ID: