Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 180 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Troy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eddy Memorial Geriatric Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Troy Center For Rehabilitation And Nursing | 3 mi | ★★★★★ | 8 | 0 |
| Van Rensselaer Manor | 3.2 mi | ★★★★★ | 22 | 0 |
| Troy Victorian Rehabilitation & Nursing Care Cntr | 4.3 mi | ★★★★★ | 7 | 1 |
| Eddy Village Green | 4.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.