Coler Rehabilitation and Nursing Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure ensure that a resident was free of any physical restraint not required to treat the resident's medical symptom and that there was documented ongoing reevaluation of the need for the restraint. This was evident in one (1) (Resident #216) of two (2) residents reviewed for physical restraints out of 40 total sampled residents. Specifically, Resident #216 was observed lying in bed between two (2) large body-sized pillows which were positioned between the mattress and bed sheet that could not be removed without removing the bed sheet. There was no documented evidence of a physician's order to use the two (2) large body-sized pillows under the bedsheet or ongoing reevaluations of the use of the pillows. The findings include: The facility policy titled, Side Rails/Bed Rails, dated 07/23/2025, documented that physical restraints include any manual method, physical, or mechanical device, material, or equipment that is attached to or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the abbreviated survey (# 2619467), the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for one (1) of three (3) residents (Resident #1) sampled. Specifically, on 09/09/2025 at 7:30 AM, Resident #1 had an unwitnessed fall and sustained a left femoral fracture (break in bone of the upper leg between the hip and knee) which the facility did not report to the New York State Department of Health until 09/16/2025 at 02:54 PM. The findings are: The facility policy titled 'Abuse Prevention and Reporting and Management of Other Reportable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during an abbreviated survey (NY00362797, the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident in one out six residents (Resident #1) sampled. Specifically, Resident #1 was observed on the floor in their room next to their bed at approximately 8:00 PM on 12/02/2024 by Certified Nursing Assistant #1. A Nursing Progress Note, by Registered Nurse #1, dated 12/02/2024 at 8:18 PM documented Resident #1 was assessed with a bruise around their right eye, a skin abrasion about 0.5 centimeter, and minimal bleeding below the right eye. The Hospital Discharge summary dated [DATE] documented Resident #1 had a laceration to their right maxillary process for which derma bond was applied. Resident #1's medical record revealed Resident #1 was observed on the floor in their room on 02/08/2024, 03/11/2024, 08/01/2024, and 12/02/2024. The Care Plan dated 02/08/2024 documented purposeful rounding every 2 hours and as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00318982, NY00315258), the facility failed to protect a resident's right to be free from physical restraint. This was evident in 1 (Resident #2) of 3 residents reviewed for abuse. Specifically, on 06/26/2023 during medication administration, Registered Nurse #3 held Resident #2's right arm firmly as they disconnected the syringe from the gastric tube. Resident #2 sustained a scratch mark on the right hand. The findings are: The facility's Policy and Procedure titled Abuse Prevention and Reporting and Management of other reportable incidents with a revised date of 11/01/2022 documented that facility residents have the right to freedom from verbal, sexual, physical, and mental abuse, corporal punishment, neglect, exploitation, mistreatment, involuntary seclusion and from misappropriation of their property and other crimes. The facility's Policy and Procedure titled Use of Restraints with a revised date of 12/23/2019 documented restraints shall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an Abbreviated Survey (NY00315258, NY00318982), the facility failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team following an allegation of abuse. This was evident in 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, on 04/21/2023, Resident #1 alleged that Food Service Aide #1 hit their leg with a food truck. Resident #1's Comprehensive Care Plan was not reviewed and revised to reflect the allegation. The findings are: The facility's Policy and Procedure titled: Abuse Prevention and Reporting and Management of other reportable incidents with a revised date of 11/01/2022 documented that every resident of the facility is assessed by the interdisciplinary team for risk of abuse or for a risk of abusing others. This assessment is conducted upon admission, quarterly, and annually; or as indicated by a change in resident's status or behavior. Following assessment, the team develops an individualized abuse care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the Recertification Survey from 1/5/23 to 1/13/23, the facility did not ensure residents remained free from physical restraints. This was evident for 3 of 3 residents reviewed for Restraints of 42 total sampled residents (Resident #s 47, 18, 68). Specifically, 1) siderails (SR) were not used with Resident #47, #18, and #68 in accordance with Medical Doctor Order (MDO). The findings are: The facility policy titled Use of Restraints dated 12/23/19 documented restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. 1) Resident # 47 had diagnoses of traumatic brain injury (TBI) and post-traumatic seizures. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 47 had severely impaired cognition, was totally dependent on two persons for bed mobility and transfer, and did not use physical restraints. Between 01/05/23 at 11:20 AM and 01/10/23 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification and Complaint survey (NY00305646, NY00276114) from 01/05/2023 through 01/13/2023, the facility did not ensure residents were adequately supervised to prevent smoking accidents. Specifically, the facility failed to provide adequate supervision and interventions to address unsafe smoking incidents in undesignated areas. Additionally, incidents of unsafe smoking were not investigated to determine adequate interventions to prevent a recurrence. This was evident for 2 of 6 residents reviewed for smoking out of 42 sampled residents. (Resident #s 314 and 78) The findings include but not limited to: The facility's policy and procedure titled Smoking Control, with the last revised date 10/05/2022, documented that Smoking is prohibited in all facility vehicles, on the facility grounds, and within the building- except in designated resident smoking areas. A smoking area has been designated. Residents are permitted to smoke only in this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification and Complaint survey from 01/05/2023 through 01/13/2023, the facility did not ensure that residents are informed and provided written information concerning their right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. This was evident for 1 of 2 residents reviewed for Advance directive out of a total sample of 42 residents (Resident #481). Specifically, the facility failed to discuss and provide information concerning the resident's right and option to formulate an advance directive for Resident #481 upon admission. The findings are: The facility Policy and Procedures titled Advance Directives and Health Care Decision making dated August 26, 2014, last revised 08/27/12, documented that the facility will provide all newly admitted adult…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification Survey from 01/05/23 to 01/13/23, the facility did not ensure a resident and their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 1 (Resident #481) of 42 total sampled residents. Specifically, Resident #481 did not receive a written copy of their BCP once developed and implemented. The findings are: The facility policy titled Care Plans - Baseline dated 10/012019 documented the BCP will be completed and implemented within 48 hours of a resident's admission. The Social Worker (SW) provides the resident a copy of the BCP if the resident is cognitively intact and documents in the resident's medical record. Resident #481 was admitted [DATE] with diagnoses of right above the knee amputation and peripheral vascular disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #481 was cognitively intact and participated in the assessment and goal setting. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification Survey from 1/5/23 to 1/13/23, the facility did not ensure that a comprehensive person-centered care plan (CCP) was developed and implemented to address a resident's needs. This was evident for 2 (Resident #488 and #489) of 42 total sampled residents. Specifically, 1) a CCP related to discharge planning was not developed or implemented for Resident #488 and 2) a CCP related to discharge planning was not developed or implemented for Resident #489. The findings are: The facility policy titled Interdisciplinary Care Plan Meeting dated 10/1/19 documented each discipline is responsible for completing and updating their specific sections of the resident's CCP. Social Workers (SW) are responsible for reviewing discharge plans and related impact upon resident adjustment. The facility policy titled Discharge Planning and Transfer dated 9/10/19 documented the SW, interdisciplinary team (IDT), and resident/family develop an individualized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the record review and interview conducted during a Recertification survey from 01/05/2023 to 01/13/2023, the facility did not ensure a resident and their representative was invited to participate in the comprehensive care plan (CCP). This was evident in 1 (Resident #78) of 42 total sampled residents. Specifically, Resident #78 was not invited to attend CCP meetings. The findings are: The facility policy titled Interdisciplinary Care Plan (ICP) Meeting dated 10/01/2019 documented the Social Worker (SW) is responsible for inviting the resident and resident representative to the ICP meeting, with advance notice prior to the date of the ICP meeting. Resident # 78 had diagnoses of chronic kidney disease and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that Resident # 78 was cognitively intact. On 01/05/2023 at 11:50 AM, an interview was conducted with Resident # 78 who stated that sometimes they are not invited to their CCP meetings. Care Conference Notes dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during a recertification survey from 1/5/23 to 1/13/23, the facility did not ensure a resident was assisted with making appointments to maintain vision abilities. This was evident for 1 of 1 resident(s) reviewed for Communication of 42 total sampled residents (Resident #324). Specifically, optometry and ophthalmology appointments were not scheduled for Resident #324. The findings are: The facility policy titled Consultations/Specialty Referrals Processing dated 4/1/11 documented residents will receive specialty evaluations upon request by their primary care physicians. Resident #324 had diagnoses of glaucoma and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #324 had moderately impaired cognition and highly impaired vision. On 01/05/23 at 02:55 PM, Resident #324 was interviewed and stated they have problems with their vision and their eyeglasses have been missing for years. Resident #324 was seen by the eye doctor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure medications and biologicals in accordance with currently accepted professional principles and expiration date, if applicable. This was evident for 1 of 22 units (Unit C12). Specifically, (1) a multi-use vial of intramuscular (IM) Lorazepam was not discarded according to manufacturer recommendation. The findings are: The undated facility policy titled Storage of Medications documented when multidose injectable vial seal is broken, the vial will be dated (a) the nurse shall place a date opened sticker on the medication and enter the date opened and (b) if a vial or container is found without a date opened, the date will automatically default to the date dispensed and the expiration date will be calculated accordingly. On [DATE] at 11:14 AM, the C12 medication room refrigerator was observed with Registered Nurse (RN) #5 present and to contain an opened Lorazepam IM 20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.