Archcare at Eger Health Care and Rehabilitation Ce

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure that a resident was cared for in a manner that maintained or enhanced dignity. This was evident for 1 (Resident #427) of 4 residents reviewed for Catheter out of 36 total sampled residents. Specifically, Resident #427's suprapubic catheter drainage bag and tubing were not covered with a privacy bag.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. This was evident for 1 (Resident #139) of 5 residents reviewed for Activities of Daily Living out of 36 total sampled residents. Specifically, Resident #139 was not showered once a week as scheduled.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 07/01/2025 to 07/09/2025, the facility failed to ensure residents with indwelling urinary catheters received appropriate care and services to manage the urinary catheter. This was evident for 1 (Resident # 427) of 4 residents out of 36 total sampled residents. Specifically, Resident #427, who had a suprapubic urinary catheter, was observed with the urinary drainage bag and the spigot lying on the floor without a barrier.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure that each resident received care and services for the provision of parenteral fluids consistent with professional standards of practice. This was evident for 1 (Resident #270) of 36 total sampled residents. Specifically, Resident #70's midline intravenous catheter insertion site dressing was undated, and the dressing appeared brownish and was peeling off.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure that food was distributed and served in accordance with professional standards for food service safety. This was evident for 1 (Resident #123) of 2 residents reviewed during the dining task observations out of 36 total sampled residents. Specifically, Certified Nursing Assistant #2 who was assisting Resident #123 at lunch time, held a sandwich with bare hands before giving it to the resident.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure garbage and refuse were disposed of properly. This was evident during the Kitchen Observation task. Specifically, the facility's waste compactor was not kept closed when not in use, exposing garbage and refuse and had the potential to attract pests.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00369908/728066), the facility failed to protect a resident's right to be free from the misappropriation of resident property and/or exploitation. This was evident for one out of nine residents (Resident #9) reviewed for personal property. Specifically, on 01/23/2025 at 7:10 AM, when counting narcotics (pain relieving) medications, Registered Nurse #1 reported a blister pack containing thirty Oxycodone 2.5 mg tablets that belonged to Resident #9 was missing from the medication cart drawer. During the facility-wide search, the empty medication blister pack had been torn into pieces in the shredder, and 30 Oxycodone tablets were missing. [...]

Inspectors wroteBased on observation, interviews, and record review, conducted during an abbreviated survey (NY00374579), the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This was evident for 1 out of 9 residents sampled (Resident #8). Specifically, on 03/09/2025 at approximately 5:22 AM, Certified Nursing Assistant #1 noted a small area of purpura (discoloration) on Resident #8's left knee and informed Registered Nurse #1. Registered Nurse #1 did not do a physical assessment, did not document in the medical record, and failed to inform the Medical Doctor, which resulted in a delay in diagnosis and treatment. On 03/10/2025, Resident #8 was transferred to the hospital due to a swollen left knee with discoloration and was diagnosed with a closed fracture of the Left femur (the thigh bone) and required surgery.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00344007), the facility failed to provide adequate supervision to a resident to prevent an accident. This was evident in one out of four residents (Resident #1) sampled for accidents. Specifically, Resident #1 was left unattended in the shower room by Certified Nursing Assistant #1 on 06/01/2024. Licensed Practical Nurse #1 and Certified Nursing Assistant #2 observed Resident #1 sitting on the wet floor in the shower room with the shower chair titled behind Resident #1 on 06/01/2024 at 9:30am. Resident #1 was transferred to the emergency room on [DATE] and returned to the facility the same day with their left arm in a sling.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 3/21/23 through 3/28/23, the facility did not ensure that it promoted and facilitated resident self-determination by supporting resident choice. Specifically, residents' bathing preferences were not honored. This was evident for 2 of the 2 residents reviewed for Choices out of 38 sampled residents. (Resident #5, and #22).

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey from 3/21/23 to 3/28/23, the facility did not ensure that resident or resident's representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, resident and resident's representatives were not consistently invited to participate in their care plan meetings and a care plan was not revised to reflect use of a hand roll. This was evident for 3 of 3 residents reviewed for Care Plan, and 1 of 2 residents reviewed for Position/Mobility out of 38 residents sampled (Residents #9, #155, #250 and #153).

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Complaint (NY00312017) survey from 3/21/23 through 3/28/23, the facility did not ensure sufficient nursing staffing to attain or maintain the well-being of each resident. Specifically, resident units did not have adequate staff to care for a census of up to 300 residents, with multiple residents reporting being given bed baths and not receiving showers as scheduled.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey from 3/21/23 to 3/28/23, the facility did not ensure a resident's right to voice care and treatment grievances and a prompt effort to resolve resident grievances. This was evident for 1 of 7 residents reviewed for Activities of Daily Living (ADL) of 38 total sampled residents (Resident #11). Specifically, the grievance process was not initiated for Resident #11 when the resident expressed concerns with ADL care received.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey conducted from 3/21/23 to 3/28/23, the facility did not ensure that the assessment accurately reflected the resident's status. This was evident for 1 of 5 residents reviewed for Unnecessary Medication (Resident #228). Specifically, the Minimum Data Set 3.0 (MDS) assessment inaccurately documented that a Gradual Dose Reduction (GDR) of psychotropic medication was attempted on 2/9/23.

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification/ Complaint survey, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, 1). a CCP was not developed and implemented for a resident prescribed an antibiotic for chronic Urinary Tract infection (UTI); and 2). a CCP was not developed and implemented for resident's use of Anticoagulant therapy. This was evident for 1 of 1 resident reviewed for Antibiotic Use (Resident #85) and 1 of 1 resident reviewed for Anticoagulant (Resident #248), out of a sample of 38 residents investigated.

Inspectors wroteBased on observations, record review, and interviews during the Recertification survey conducted 3/21/23 to 3/28/23, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene. This was evident for 1 of 7 residents (Resident #11) reviewed for ADLs. Specifically, Resident #11 did not consistently receive a shower twice weekly as scheduled.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey conducted from 3/21/23 to 3/28/23, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was evident for 1 of 1 resident (Resident #71) reviewed for Respiratory Care out of a total sample of 38 residents. Specifically, Resident #71 had a Physician's order to receive 2 liters of oxygen per minute continuously and was observed receiving 4 liters of oxygen per minute on four consecutive days.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 3/21/2023 to 3/28/2023, the facility did not ensure an account of all controlled drugs was maintained and periodically reconciled. This was evident for 1 of 6 units (Unit 3E) observed for Medication Storage. Specifically, a Registered Nurse (RN) on Unit 3E did not reconcile a narcotics supply count.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey conducted from 3/21/23 to 3/28/23, the facility did not ensure that a medication regimen review (MRR) performed by the consultant pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident for 1 of 5 residents reviewed for Unnecessary Medications Review out of a total sample of 39 residents (Resident #228). Specifically, a pharmacy recommendation to perform a lipid panel for Resident #228 was agreed upon by the Attending Physician (AP), but the test was not completed.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 3/21/2023 to 3/28/2023, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was observed on 1 of 6 units during the Medication Storage task (Unit 3). Specifically, one vial of expired influenza vaccine was stored in the medication storage room refrigerator on Unit 3.

Inspectors wroteBased on observations and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, (1) BiPap and Nebulizer Masks were observed touching the wall and table without a plastic barrier on several occasions (Resident #126, Resident #136). (2) Two staff members were observed without personal protective equipment (PPE) in the room of the residents on transmission-based precaution (Resident #85, Resident #249, and Resident #51). This was evident for 5 random resident observations on 2 of 8 resident floors observed for Infection Control Practices(Floor 6 and 8).