Eddy Heritage House Nursing And Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, New York.
- Location
- 2920 Tibbits Avenue, Troy, New York 12180
- CMS Provider Number
- 335760
- Inspections on file
- 16
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 9 (2 serious)
Citation history
Health deficiencies cited at Eddy Heritage House Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
A resident admitted for respite care with multiple comorbidities received four incorrect doses of morphine due to a transcription error and incomplete verification process. The resident became unresponsive with unstable vital signs, but staff did not provide interventions to reverse the opioid effects or consistently monitor the resident's condition. Communication failures led to delays in notifying the family, hospice, and facility leadership about the error, and the resident died without documented evidence of appropriate assessment or intervention.
A resident with multiple comorbidities was administered four incorrect doses of morphine sulfate due to a transcription error during order entry, resulting in a total of 80 mg over 12 hours. The error was not identified by the triple check process or by staff administering the medication, and the resident, who had not previously received morphine, became unresponsive and died. Staff did not follow medication administration and error reporting policies, and concerns raised by the family regarding the resident's condition and possible use of Narcan were not acted upon.
Surveyors found that multiple residents did not receive their medications within the prescribed time frames, and medical providers were not notified of these delays as required by facility policy. LPNs cited heavy workloads, computer issues, and resident unavailability as reasons for late administration, and staff interviews confirmed that documentation of provider notification was lacking.
A resident admitted for respite care with multiple serious diagnoses was administered morphine sulfate by nursing staff who did not question the order or dosage because the resident was on hospice, despite no prior history of morphine use. Staff failed to assess or respond to the resident's unresponsiveness after medication administration, and concerns raised by family about the use of Narcan were dismissed. This resulted in compromised dignity and access to appropriate care.
A resident received multiple incorrect doses of morphine, and despite facility policy and agreements requiring immediate notification, neither hospice nor the resident's representative was promptly informed of the medication error. The error was discovered and corrected by an RN, who notified the physician but did not escalate the issue to administration or the DON, resulting in delayed communication with the family.
A resident received multiple incorrect doses of morphine sulfate due to a transcription error, resulting in unresponsiveness and death. Despite facility policy and regulatory requirements, the serious adverse event was not reported to the NYS DOH, as the administrator, after consulting with leadership, did not believe the death was related to the medication error.
A physician failed to provide adequate supervision and signed multiple inconsistent morphine orders for a resident on hospice respite care, resulting in the administration of 80 mg of morphine over 12 hours. Pharmacy staff repeatedly sought clarification due to conflicting dosages and concentrations, but the orders remained unclear, and there was no documented physician follow-up after the medication error was discovered.
A resident with dementia, end-stage renal disease, and atrial fibrillation received routine doses of morphine sulfate despite no documented pain or shortness of breath, and with pain levels recorded as zero at each administration. Facility staff failed to ensure medication administration was clinically justified, contrary to policy and professional standards.
Facility administration failed to provide effective oversight and resource allocation, resulting in neglect, a significant medication error involving morphine sulfate, and lack of proper reporting and communication. Leadership and clinical staff were unaware of the resident's decline and did not ensure timely investigation or notification, leading to compromised resident safety and regulatory noncompliance.
A resident with dementia, squamous cell carcinoma, and anemia reported that a staff member was rough and mean, causing a bruise. The facility failed to report this suspected abuse to the New York State Department of Health within the required two-hour timeframe, as mandated by their policy. Both the Assistant Director of Nursing and the Administrator acknowledged the reporting failure.
The facility failed to thoroughly investigate alleged violations of abuse, neglect, or mistreatment for five residents. Investigations lacked interviews, witness statements, and identification of causes or preventive measures, leading to incomplete investigations and a lack of preventive actions.
The facility failed to ensure immediate and thorough assessments for two residents, one with an injury alleged to be caused by abuse and another with new onset pain leading to a delayed fracture diagnosis. Staff did not follow procedures for immediate health concerns, resulting in deficiencies in care.
Failure to Prevent Neglect and Respond to Opioid Overdose
Penalty
Summary
A facility failed to protect a resident from neglect, resulting in the administration of four incorrect doses of morphine sulfate totaling 80 milligrams over a 12-hour period. The resident, who was admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, had not previously received morphine at home. The error originated from a transcription mistake during the medication reconciliation process, where three out of five morphine orders were entered incorrectly and the facility's triple check system was not fully completed, lacking a third verification signature. The error was discovered only after a nurse questioned the order, at which point the incorrect order was discontinued and a corrected order was entered. Following the medication error, the resident became lethargic and unresponsive, with unstable vital signs including low blood pressure and oxygen saturation. Despite these changes, there was no documented evidence that the facility provided interventions to reverse the effects of the opioid overdose, such as administering naloxone (Narcan), even after the family inquired about it. Additionally, there was a lack of documented monitoring, assessment, or treatment for the resident's decline after the error was identified. Vital signs and nursing assessments were not consistently recorded, and there was no evidence of physician oversight or coordination with hospice regarding the medication error. Communication failures further contributed to the deficiency. The resident's representative was not notified of the medication error until after the resident's condition had significantly deteriorated. Hospice was not informed of the medication error, and attempts to contact hospice during the resident's decline were unsuccessful due to incorrect contact information. Key facility leadership, including the Director of Nursing and Administrator, were not promptly informed of the incident, and staff interviews revealed a lack of awareness and documentation regarding the resident's condition and the actions taken. The resident ultimately expired without documented evidence of appropriate monitoring or intervention following the overdose.
Removal Plan
- Post Hospice contact information in each nursing unit and include on the face sheet for residents actively on Hospice.
- Make the contact for Community Hospice visible at accessible locations such as a nursing station on each resident unit.
- Ensure that for all residents enrolled in Hospice services, the contact number for Community Hospice is visible and accessible under contacts on the residents' face sheets in both electronic and paper charts.
- Update medication error reporting policy to require the Physician/Nurse Practitioner, upon notification of medication error, to provide direction for monitoring, duration of monitoring, and expected follow up communication.
- Require documentation of the nature of the incident, individuals notified (including family and hospice as applicable), actions taken, orders received, results of continued monitoring, assessments, and communication.
- In-service all on-call Physicians and Nurse Practitioners regarding high-risk medications and review of electronic ordering for safe dosing.
- Educate all nursing staff, including agency staff, by the nursing educator/designee on the updated Medication Error Reporting policy, including directions on provider and family notification as well as resident monitoring and documentation requirements.
- Use education sign-in sheets to document that in-house and agency nurses were educated; educate remaining agency nurses if they return to the facility.
- Compare transcribed orders with original provider order for accuracy; complete and document checks in the paper chart for the next two consecutive shifts.
- Educate all nursing staff (including agency staff) by the nurse educator, supervision, or designee regarding medication reconciliation, medication transcription, triple check, and safe medication administration practices.
- In-service all in-house and agency nurses regarding 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.
Significant Medication Error Resulting in Resident Death
Penalty
Summary
A significant medication error occurred when a resident admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, was administered four incorrect doses of morphine sulfate, totaling 80 milligrams over a 12-hour period. The original hospice order specified morphine 5 mg by mouth every four hours as needed, but during the admission process, a transcription error resulted in the order being entered as 20 mg per dose. This error was not identified during the triple check process or by subsequent staff administering the medication. Multiple staff members, including registered nurses and licensed practical nurses, were involved in the medication administration and order entry process. The error was not questioned until after the fourth dose had been given, at which point a nurse reviewed the medication and brought the issue to the attention of supervisory staff. Interviews revealed that staff assumed the order was correct, particularly because the resident was on hospice care, and did not verify the appropriateness of the dose or question the high dosage of morphine being administered. The resident, who had not previously received morphine at home, became unresponsive and died following the administration of the incorrect doses. Family members raised concerns about the resident's condition and the potential use of Narcan, but were advised by facility staff and a physician that Narcan was not appropriate or effective at that time. The facility's policies on medication administration and error reporting were not followed, and the error was only identified after significant harm had occurred.
Removal Plan
- Narcotic orders were reviewed for ongoing appropriateness and safety by Medical Director #1.
- Narcotic orders were reviewed for ongoing appropriateness and safety. 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.
- All active medication orders were reviewed 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 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.
- ‘Transcription of Orders' policy was developed 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 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.
- 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 in house nurses and agency nurses educated. Agency nurses left to educate if they return to the facility.
- Chief Nursing Officer #1 stated that the medication nurse was educated regarding an end date needed for the order and printing orders to place in the chart to begin the triple check process.
- Medical Director #1, and/or Administrator #1 and/or Chief Nursing Officer #1 would check orders from the previous day.
- Nurse Managers were responsible for completing audits on triple check and would bring audit results to Quality Assurance monthly meetings.
- 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.
Failure to Administer Medications Timely and Notify Providers
Penalty
Summary
Surveyors identified that the facility failed to ensure residents received medications in accordance with provider orders and professional standards of practice. Observations, interviews, and record reviews revealed that four residents did not receive their scheduled medications within the prescribed time frames. The facility's policy required medications to be administered as ordered, and for staff to notify medical providers if medications were given late. However, medications were consistently administered late across various units, and there was no documented evidence that medical providers were notified of these delays. Specific incidents included residents with complex medical conditions such as fractures, dementia, hypertensive crises, heart failure, and anxiety disorders. For example, one resident with hypertension and dementia was scheduled to receive a Lidocaine patch and Metoprolol at specific times, but these were administered late. Another resident with heart failure and respiratory issues received Bumetanide later than ordered, and questioned the nurse about the inconsistent timing. In each case, the responsible LPNs acknowledged the delays, citing reasons such as heavy medication passes, computer system issues, and residents being unavailable due to appointments or meetings. Despite staff awareness of the need to notify medical providers about late medication administration, there was no documentation of such notifications in the electronic medical record. Interviews with nursing staff confirmed that while they sometimes verbally informed providers, they often forgot to document these communications. The facility also relied heavily on agency nurses, and staff reported that high workload and frequent interruptions contributed to the delays in medication administration.
Failure to Ensure Dignified and Equal Care Due to Unquestioned Medication Error for Hospice Resident
Penalty
Summary
The facility failed to ensure equal access to quality care and uphold the rights to dignity and self-determination for a resident receiving hospice services. Staff did not question, assess, or respond appropriately to a significant medication error involving the administration of morphine sulfate. The resident, admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, had not previously received morphine at home according to both hospice records and statements from health care proxies. Despite this, staff administered morphine as ordered without verifying the appropriateness of the dose or the resident's prior exposure to the medication. Licensed Practical Nurses involved in the resident's care reported that they did not question the morphine order or dosage because the resident was on hospice, even though one nurse later acknowledged the dose seemed excessive. The medication was administered multiple times, and concerns about the dosage were only raised after several doses had already been given. Registered nursing staff also deferred to the hospice status of the resident, focusing on comfort rather than reassessing the medication order or the resident's response to the drug. Family members observed that the resident was unresponsive and could not be awakened after the administration of morphine. When concerns were raised about the resident's condition and the possibility of using Narcan to reverse opioid effects, facility staff and an unnamed physician advised against it, stating it was not safe or effective at that time. The lack of timely assessment and intervention following the medication error compromised the resident's right to dignified and appropriate care, as required by facility policy and federal regulations.
Failure to Notify Hospice and Resident Representative of Significant Medication Error
Penalty
Summary
A significant medication error occurred involving a resident who was admitted for respite care and received four incorrect doses of morphine sulfate totaling 80 milligrams over a twelve-hour period. Despite facility policies and a service agreement with hospice requiring immediate notification of significant changes or medication errors to hospice and the resident's representative, there was no documented evidence that hospice was notified of the error. Additionally, the resident's representative was not informed of the medication error until nearly three weeks later, as indicated by a progress note documenting a meeting with the family to review the events surrounding the resident's passing. Interviews revealed that after the error was discovered, the responsible RN discontinued the incorrect order, notified the physician, and obtained a new order, but did not inform the Director of Nursing or administration at that time. The administrator was not present during the incident and only became aware after receiving a voicemail from the resident's representative. The family had attempted to contact the DON but did not receive a response. The medical director confirmed that the family was not immediately informed about the medication error.
Failure to Timely Report Serious Medication Error Resulting in Resident Death
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect was reported immediately, as required by state and federal regulations. Specifically, a resident admitted for respite care received four incorrect doses of morphine sulfate totaling eighty milligrams over a twelve-hour period due to a transcription error. This medication error resulted in the resident becoming lethargic, unresponsive, and experiencing unstable vital signs, ultimately leading to the resident's death. Despite the family's inquiry about administering Narcan to reverse the opioid effects, the facility did not provide this intervention. Facility policy required that all serious adverse events, including medication errors resulting in harm, be reported to the New York State Department of Health (NYS DOH). However, there was no documented evidence that the event or the medication error was reported to the NYS DOH. During interviews, the administrator stated that they did not believe the resident's death was caused by the morphine administration and, after consulting with the executive director and medical director, decided not to report the incident. This failure to report was not in accordance with facility policy or regulatory requirements.
Physician Failed to Provide Proper Supervision and Accurate Medication Orders
Penalty
Summary
A deficiency was identified when a physician failed to provide proper supervision of medical care for a resident admitted for respite care under hospice services. The physician signed multiple, inconsistent orders for morphine sulfate oral solution with varying concentrations, dosages, and administration instructions within a short period. These orders included conflicting directions such as 5 milliliters every 4 hours, 1 milliliter every 4 hours, and one-time doses, leading to unclear and inaccurate medication instructions. As a result, the resident received 80 milligrams of morphine over a 12-hour period. Pharmacy records documented repeated attempts to clarify the morphine orders with facility staff and the physician due to concerns about dosing and concentration accuracy. Despite these efforts, the orders remained inconsistent, and the pharmacy had to intervene multiple times to clarify and authorize the correct dosages. There was also a request to access Narcan for the resident, but records indicate it was never administered. Interviews revealed that the physician was not typically responsible for respite residents but was asked to handle this resident's orders. The physician admitted to not carefully reviewing the orders, particularly the concentration and dosage, and did not realize the error at the time. After the medication administration issue was discovered, there was no documented evidence that the physician provided any follow-up instructions or care to the resident.
Unnecessary Administration of Morphine Without Clinical Indication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications, as required by policy and regulation. Specifically, morphine sulfate, a strong opioid, was administered as a routine, standing medication to a resident admitted for respite care, despite no documented clinical evidence of pain or shortness of breath. The medication administration record showed that morphine was given every four hours, with each administration accompanied by a documented pain level of zero. There was no evidence in the clinical documentation to support the need for morphine, and the resident had not previously used morphine at home nor exhibited pain during hospice visits. The resident in question had diagnoses including dementia, end-stage renal disease, and atrial fibrillation, and was rarely understood according to a mental status assessment. The facility’s own policies required that medications be administered according to provider orders and professional standards, and that clinical documentation reflect assessments, identification of problems, and responses to care. Despite these requirements, the administration of morphine was not supported by clinical findings, and a nurse later acknowledged that the dose was excessive and should have been identified as such.
Administrative Failures Lead to Neglect and Medication Error Resulting in Resident Death
Penalty
Summary
Facility administration failed to provide effective oversight, policy enforcement, and resource allocation, resulting in multiple deficiencies that compromised resident safety and well-being. Specifically, the facility did not ensure proper use of its resources, including staff, policies, and communication systems, to protect a resident. Deficiencies cited include failure to prevent neglect, significant medication errors, lack of resident dignity, failure to report adverse events to the State Survey Agency, and failure to meet professional standards of care. The facility also failed to ensure that the medical director fulfilled their responsibilities and that resident care was properly supervised by a physician. These failures collectively contributed to a medication error involving morphine sulfate, which was transcribed as a scheduled dose instead of as needed, and this error was not promptly identified or addressed. Interviews revealed that key leadership, including two Directors of Nursing and the Administrator, were unaware of the circumstances surrounding the resident's decline and death, and did not recall being notified or involved in the incident investigation. The Administrator attributed the medication error to confusing hospice orders and staff overstimulation, and stated that errors were reviewed only after the incident. The Medical Director acknowledged the event as a significant medication error, with family communication occurring later. The Administrator also indicated that guidance was sought from the Executive Director and Medical Director regarding reporting the incident to the State Department of Health, and was advised not to report it. These actions and inactions resulted in the facility's failure to ensure resident safety and compliance with regulatory requirements.
Failure to Report Suspected Abuse in a Timely Manner
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made. Specifically, an allegation of physical abuse reported by a resident on 5/15/2023 was not reported to the New York State Department of Health. The resident, who had diagnoses of dementia, squamous cell carcinoma, and anemia, reported that the staff member who dressed them that morning was rough and mean, causing a bruise on their right arm. The facility's policy required that such allegations be reported immediately, but this was not done. The investigation summary form documented that the resident reported the incident to two daytime Certified Nurse Aides, stating that the overnight aide was mean and rough, causing the bruise. Despite this, the section of the form titled Department of Health Notification was left blank, and no reports were submitted to the state. Both the Assistant Director of Nursing and the Administrator acknowledged that the incident should have been reported within two hours, but it was not. This failure to report the suspected abuse in a timely manner constitutes a deficiency in the facility's compliance with state regulations.
Failure to Thoroughly Investigate Alleged Violations
Penalty
Summary
The facility did not ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source, were thoroughly investigated for five residents. Specifically, for Resident #1, the facility failed to conduct a thorough investigation when the resident alleged abuse by a Certified Nurse Aide, as the investigation lacked interviews and witness statements from staff working at the time of the incident and did not identify the cause of the bruise or steps to prevent reoccurrence. For Resident #2, the facility did not determine the cause of a fracture identified and did not include steps to prevent reoccurrence of injury for the resident. For Resident #3, the facility's investigation began five days after the resident's unwitnessed fall and did not identify the cause or corrective actions to prevent reoccurrence. Additionally, for Residents #4 and #5, the facility's investigations did not identify non-adherence to the residents' care plans as contributing factors and did not include appropriate corrective actions to prevent reoccurrence. The investigations lacked thoroughness, including interviews with all potentially involved staff and residents, and did not document changes to care plans or processes. The facility's policy on Abuse Prevention and Investigation was not followed, as investigations did not include a record of interviews, an explanation of evidence reviewed, or conclusions with a discussion of their basis. The facility failed to make necessary changes to care plans, policies, procedures, and staff education as identified by the investigations. This led to incomplete investigations and a lack of preventive measures for future incidents.
Failure to Ensure Immediate Assessment and Care
Penalty
Summary
The facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For Resident #1, the facility failed to conduct an immediate and thorough assessment of an injury alleged to be caused by abuse. The resident reported to a Certified Nurse Aide that an overnight aide was rough during care, causing a bruise on the right arm. However, the medical record and investigation summary form lacked documentation of a Registered Nurse's assessment of the injury, including details such as the bruise's size, shape, color, or characteristics. The Assistant Director of Nursing confirmed that such an assessment should have been conducted immediately following the allegation. For Resident #2, the facility did not ensure an assessment of new onset pain, resulting in a delay of treatment for a fracture. The resident, who had diagnoses including hemiplegia and mild cognitive impairment, complained of left leg pain over several days. Despite multiple progress notes documenting the pain and swelling, there was no nursing or medical provider assessment until the resident's family intervened, leading to an x-ray that confirmed a fracture. The Assistant Director of Nursing and a Registered Nurse both stated that new onset pain complaints should have been assessed immediately and not merely placed in the Doctor's Book. Interviews with facility staff, including the Assistant Director of Nursing, a Registered Nurse, and a Physician, revealed that the facility's procedures for handling immediate health concerns were not followed. The Physician indicated that emergent issues should be directly communicated rather than placed in the Doctor's Book. The failure to promptly assess and address the residents' conditions led to deficiencies in the care provided to both residents.
Latest citations in New York
A resident with dementia, severely impaired cognition, and known risk for dehydration had documented 0% meal intake over multiple consecutive meals, with CNAs recording refusals but not documenting fluids and not reporting the poor intake to an LPN or RN as required by facility policy. Nursing staff, including LPNs and RN supervisors, reported they were unaware the resident was not eating and did not assess or notify the MD despite ongoing 0% intake and the absence of a care plan addressing meal refusal or poor appetite. The resident was only assessed by an RN after a marked change in mental status and rapid decline were observed, at which point the MD was finally notified and medical interventions were initiated, resulting in a deficiency for failure to provide care in accordance with professional standards and the facility’s nutrition and hydration policies.
A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
The facility failed to maintain adequate nurse and CNA staffing to meet resident needs as defined in its own facility assessment, with multiple shifts where minimum nurse coverage was not met and frequent reliance on minimal CNA staffing across units. On several overnight and day shifts, too few nurses were present to cover all units, and one nurse sometimes had to function as both supervisor and direct care nurse. CNA staffing was at or below minimal levels on most days reviewed, leading to delays in getting residents out of bed, late meal service, and missed or postponed showers. Residents reported not having enough staff available at night and difficulty getting up in the morning, while CNAs and LPNs described high acuity, incomplete or delayed cares, and inconsistent documentation due to short staffing. Facility leadership acknowledged ongoing staffing challenges, open positions, and that existing minimum staffing numbers were not adequate or safe to ensure timely completion of resident care tasks.
The facility failed to maintain safe, clean, and homelike conditions in multiple rooms on three units. One room had stained floors, a water puddle near a radiator, peeling molding, missing closet doors, bathroom stains, missing tiles, and debris in a light fixture, with no related entries in the maintenance log. Another room had a hospital bed plugged into an electrical outlet with no cover plate and exposed wires near the bed. Additional rooms had unpacked boxes, missing closet doors, broken or missing curtains and privacy drapes, and broken dresser drawers, while a resident reported long-standing broken drapes and unassembled storage they had purchased. Maintenance staff reported they relied on work orders, did not routinely enter individual rooms during rounds, and lacked needed closet doors, contributing to these unresolved environmental issues.
Surveyors found that the facility failed to ensure necessary ADL and personal hygiene care for several dependent residents. One resident with severe cognitive impairment and incontinence had no documented showers for an entire month and multiple days without recorded dressing, hygiene, toileting, or transfer assistance despite care plan requirements. Another resident with multiple sclerosis and neurogenic bladder, fully dependent for showers, had numerous missed or undocumented scheduled baths over two months and reported that showers rarely occurred and that their hair was dirty. A third resident with cognitive and psychiatric conditions, care-planned for daily support with personal hygiene, was repeatedly observed with facial stubble despite requesting shaving, and had extensive omissions in bathing and personal hygiene documentation. Staff across roles acknowledged frequent failures in CNA documentation of ADLs, citing short staffing, high acuity, and login issues, resulting in an inability to confirm whether required hygiene care was consistently provided.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Failure to Assess and Respond to Prolonged Poor Oral Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding nutrition and hydration monitoring and response. The resident had dementia with declining mental and functional status, pulmonary venous congestion, severely impaired cognition, and required partial/moderate assistance with eating. A dietary care plan identified the resident as at risk for dehydration due to dementia and varied oral intake, with interventions to observe for signs and symptoms of dehydration and explore reasons for decreased intake. Physician orders placed the resident on a no added salt mechanical soft diet with thin liquids, later downgraded to puree solids per speech therapy. Certified Nursing Assistant (CNA) documentation showed that the resident had no documented oral intake from the morning of 03/14/2026 through early afternoon on 03/16/2026, totaling eight missed meals. CNAs reported that the resident had a history of poor appetite, combative behavior during care, and variable intake ranging from 25% to 75% of meals. For the relevant period, CNAs stated they documented 0% food consumption because the resident refused to eat, and they acknowledged offering fluids or juice but did not document fluid intake. They also stated they did not report the resident’s refusal to eat to the LPN, despite facility policy requiring staff to report poor intake and meal consumption of less than 50% to the nurse immediately. Nursing staff, including LPNs and RN supervisors, reported that they did not receive information from CNAs that the resident was not eating or drinking during the days in question. LPNs stated they would have encouraged intake and notified supervisors if they had known the resident was not eating, and they reported that they did not observe the resident as weak or less responsive during their shifts. The RN supervisors stated they did not receive reports of poor appetite or meal refusal and indicated that CNAs were expected to notify the unit nurse when a resident refused or did not eat. There was no care plan addressing the resident’s refusal of meals or poor appetite, and there was no documentation that a nurse assessed the resident for poor intake or that the physician was notified until 03/16/2026 at 3:44 PM, when the RN Supervisor assessed the resident with a change in mental status, rapid decline, weakness, lethargy, and minimal responsiveness, and noted that the resident had not been eating and was spitting up brown secretions. Only at that time was the physician contacted and medical interventions initiated. The facility’s own policy on Meal Consumption required CNAs to document intake percentages for each meal, record refusals and behaviors, and promptly report poor intake, and required nurses to review intake documentation daily, assess residents with poor intake, document interventions and outcomes, and notify the medical provider as indicated. The policy also required physician notification when intake was consistently less than 50% or when significant decline in intake was observed. Despite this, the resident’s extended period of no documented oral intake and repeated 0% meal consumption entries were not acted upon by nursing staff, and the physician was not notified until after a significant change in condition was observed. This sequence of inaction and lack of assessment and notification in the face of documented poor intake led to the cited deficiency under 10 NYCRR 415.12.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision during a mechanical lift transfer, resulting in a resident fall and injury. Facility policy for "Resident Transfer Using a Total Mechanical Lift" required that two or more caregivers be present and assisting at all times, with at least two caregivers having hands-on contact with the resident and the lift. The resident involved had dementia and type 2 diabetes mellitus, was cognitively impaired, and was assessed on the Minimum Data Set as needing assistance of two staff members for transfers. The resident’s care plan also documented dependence on two staff for transfers using a gait belt. On the date of the incident, the resident was transferred via mechanical lift by a single CNA, contrary to policy and the resident’s assessed needs. The CNA reported they could not find another staff member to assist, knew they should not perform the transfer alone, but proceeded because the resident repeatedly requested to go to bed and it was the end of the CNA’s shift. The resident was later found on their left side near the mechanical lift with a six-inch laceration on the left leg and was sent to the emergency room. Subsequent examination of the sling and lift by nursing leadership found the equipment to be in good working order. Staff interviews confirmed that two staff members were expected for mechanical lift transfers and that other aides had been available on the unit at the time of the incident.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Maintain Adequate Nurse and CNA Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms Across Three Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.
Failure to Provide and Document Required ADL and Hygiene Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene care.
Failure to Follow Care Plans and Post-Fall Protocols Resulting in Inadequate Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
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