Eddy Heritage House Nursing and Rehabilitation CTR

In the surveyor’s words

From the most serious findings on record at Eddy Heritage House Nursing and Rehabilitation CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 26, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF760Nov 26, 2025

  Based 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.The facility policy and procedure titled Medication Administration dated… […]

• Actual harm, isolatedF689Dec 16, 2022

  Based on record review and interviews during an abbreviated survey (NY00292926), the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #2) of 2 residents reviewed. Specifically, the facility did not ensure Resident #2, who was visually impaired, was to be served hot beverages in an adaptive cup with a lid to prevent avoidable accidents. The resident was served a hot beverage in a paper cup without a lid and spilled the contents on themselves, resulting in second degree burns on their chest and thigh. […]

• No harm, potential for more than minimal, patternF684Nov 26, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF585Feb 27, 2024

  Based 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. […]