Eddy Heritage House Nursing And Rehabilitation Ctr

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

at 12:12 PM, Health Care Proxy #2 stated Resident #1 had not received any medications prior to their admission to the facility. During an interview on 11/19/2025 at 1:49 PM, Licensed Practical Nurse #2 stated

they were Resident #1's medication nurse for the overnight shift starting 10/08/2025. They recalled giving

the resident the ordered morphine sulfate.? They stated they assumed the order was correct and did not question the dosage of morphine sulfate because the resident was on hospice.? They stated they administered 20 milligrams of morphine on 10/09/2025 at 2:00 AM and 6:00 AM as ordered.?? During an

interview on 11/18/2025 at 10:45 AM, Licensed Practical Nurse #1 stated that the dose seemed excessive, however because Resident #1 was on hospice, they did not question it prior to giving the medication.? Licensed Practical Nurse #1 stated they questioned the morphine dose after they had given the second dose on their shift at 2:00 PM on 10/09/2025. During an interview on 11/19/2025 at 10:40 AM, Registered Nurse #4 stated on 10/09/2025, Licensed Practical Nurse #1 came to them to question the morphine sulfate order, and that when they left for the day around 3:45 PM, they stated 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. During an interview on 11/18/2025 at 12:12 PM, Health Care Proxy #2 stated Resident #1 had not received any medications prior to their admission to the facility. They stated they left the facility around 2:00 PM on 10/08/2025 and returned around 4:00 PM on 10/09/2025. They stated Resident #1 was sleeping soundly enough to be snoring and they were unable to wake them. Health Care Proxy #2 stated

they asked unnamed staff if Resident #1 had been like that all day and the unnamed staff reportedly stated yes. An unnamed doctor spoke to Health Care Proxy #2 and mentioned the resident had received morphine, but it was a low dose. The unnamed doctor reportedly stated to Health Care Proxy #2 that Narcan (also known as naloxone, a medication used to reverse or reduce the effects of opioids) was not safe to use and Health Care Proxy #2 was advised to let Resident #1 sleep it off. Health Care Proxy #2 stated they left the facility after 7:00 PM on 10/09/2025 and were called back to the facility on [DATE REDACTED] at 4:00 AM because Resident #1 was dying. Upon arrival, Health Care Proxy #2 again asked if Resident #1 should receive Narcan. Unnamed facility staff told them that Narcan would be ineffective at that time. 10 New York Codes, Rules, and Regulations 483.10 (c)(2) and 483.25 (d)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

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)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The document Service Agreement by and between [Hospice Vendor #1] and [Facility] dated 10/24/2027, documented promptly upon admission of a hospice patient, who has not been residing in a nursing home, to the Nursing Facility and consent of the Hospice Patient (or his/her Authorized Representative), Hospice would furnish nursing with a copy of the then-current hospice plan of care. Hospice and nursing facility agreed to immediately notify each other of any identified change in the condition of a residential hospice patient which required supplementation, modification or alteration of the Plan of Care, including but not limited to changes in medications or the ordering of clinical laboratory testing or other services. The policy Resident Rights effective date 5/28/2024, documented Under Notification of Change that the facility must immediately notify the resident, physician, and/or the resident's representative when there was an accident that resulted in injury, a significant change in the resident's health status, or a need to alter treatment significantly, including a need to change a current treatment, in addition to discontinuing a current treatment or commencing a new treatment.? The policy Medication Errors and reporting dated 10/10/2021, documented medication events included transcription errors. The purpose of the policy was to ensure prompt identification, reporting, documentation, investigation and correction of all medication events (including errors and near misses) to protect resident safety and comply with regularity requirements. It was further documented that the family and/or the designated representative would be notified about the error and follow up plan. Resident #1 was admitted on [DATE REDACTED] for respite care.

The resident received four (4) incorrect doses of morphine sulfate totaling eighty (80) milligrams over a twelve (12) hour period on 10/09/2025. There was no documented evidence that hospice was notified of the medication error that Resident #1 received. There was no documented evidence that the resident's representative was notified of the medication error until 10/28/2025, as evidenced by a progress note entered by Medical Director #1 documenting a meeting with the resident's representatives to review the events surrounding the resident's passing. 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)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

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)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

(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 REDACTED] 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 REDACTED] 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 REDACTED]. Observed to be true [DATE REDACTED], effective date [DATE REDACTED] by review of the revised policy supplied to surveyors.All on-call Physicians and Nurse Practitioners (for dates [DATE REDACTED]-[DATE REDACTED]) 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 REDACTED]. 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 REDACTED]. 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 REDACTED] at 12:18 PM, surveyor identified 1 (one) in house nurse Registered Nurse #11 was not educated prior to their shift on [DATE REDACTED] and was actively working on their shift. Registered Nurse #11 was educated on [DATE REDACTED] 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)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 REDACTED]. 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 REDACTED], 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 REDACTED], 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 Department of Health. It was also documented to document all details in the resident's medical record.

Resident #1 was admitted on [DATE REDACTED] 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 REDACTED]. 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 REDACTED] at 6:20 AM.? ? An undated Medication Event Investigation documented, on [DATE REDACTED] 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 REDACTED] 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 REDACTED] 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)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

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)

F 0684

Regulations 415.12

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

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)

F 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

by mouth one time for pain for 2 days may remove from pyxis Quantity: 3. Quantity clarified per Registered Nurse #3, per Physician #1 at 7:36 PM as 1 milliliter and authorized to use 4 times 5 milligram doses out of Omnicell by pharmacist. On 10/08/2025 at 6:14 PM- Morphine 100 milligrams per 5 milliliters electronic prescription medication order sent into pharmacy for Resident #1 with directions Give 1 milliliter by mouth every 4 hours for pain Quantity:1. Clarified as 1 milliliter per Physician #1 at 7:15 PM by pharmacist.

Authorized to use out of Omnicell to Registered Nurse #1 by pharmacist at 7:19 PM. On 10/09/2025 at 3:46 PM- Morphine 20 milligrams per 1 milliliter electronic prescription medication order sent into pharmacy for Resident #1 with directions Give 5 milligrams by mouth every 4 hours for pain/shortness of breath every 4 hours. Quantity clarified as 30 doses per Physician #1 at 4:15 PM by pharmacist. On 10/09/2025 at 6:42 PM Pharmacist recorded an alert in the profile for Resident #1 as Spoke with Director of Nursing #2.

Physician #1 sent Morphine 20 milligram syringe in error and it got corrected to 5 milligram dose. Stated

they gave Resident #1 4 doses and will Narcan Resident #1 out of pyxis. 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)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

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)

F 0757

Licensed Practical Nurse #1 stated it should have been caught as an excessive dose. 10 New York Codes, Rules, and Regulations 415.12(I)(1)

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

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)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 REDACTED] at 5:28 PM. The facility's Immediate Jeopardy Removal Plan dated [DATE REDACTED] at 10:20 PM was accepted. The Immediate Jeopardy was removed on [DATE REDACTED] at 2:47 PM. *************************************************************************************Based on observations, interviews and record review conducted on [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED], the facility's corrective actions were fully implemented effective [DATE REDACTED] at 2:47 PM and included the following: 35 narcotic orders were reviewed for ongoing appropriateness and safety by Medical Director #1 on [DATE REDACTED]. No corrections were required. 51 narcotic orders were reviewed for ongoing appropriateness and safety on [DATE REDACTED]. 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 REDACTED] and [DATE REDACTED] 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 REDACTED] -[DATE REDACTED]) 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 REDACTED]. ‘Transcription of Orders' policy was developed on [DATE REDACTED] 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 REDACTED]. 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 REDACTED] 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 REDACTED] at 5:45 PM, Chief Nursing Officer #1 stated that the medication nurse was educated on [DATE REDACTED] 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 REDACTED]. They stated Nurse Managers were responsible for completing audits on triple check and would bring audit results to Quality Assurance monthly meetings. On [DATE REDACTED] 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)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eddy Heritage House Nursing and Rehabilitation Ctr

2920 Tibbits Avenue Troy, NY 12180

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)

F 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

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)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet