Coler Rehabilitation and Nursing Care Center

In the surveyor’s words

From the most serious findings on record at Coler Rehabilitation and Nursing Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF604Jan 13, 2023

  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. […]

• No harm, potential for more than minimal, patternF609Jan 13, 2023

  Based on interviews and record review conducted during the Recertification and Complaint survey (NY00284350, NY00303282, and NY00276114) from 01/05/2023 to 01/13/2023, the facility did not ensure violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately, but not later than 2 hours after the allegations were 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. This was evident for 6 of 6 residents reviewed for Abuse out of 42 total sampled residents (Resident #s 278, 285, 170, 347, 245, and 251). […]

• No harm, potential for more than minimal, patternF689Jan 13, 2023

  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. […]

• No harm, potential for more than minimal, patternF880Jan 4, 2021

  Based on observation, record review, and interview conducted during the COVID-19 Focused Infection Control Survey completed on 01/04/21, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, for 1 (unit C-52) of ten units reviewed a Certified Nursing Assistant (CNA #1) was observed not donning (putting on) gown and gloves prior to performing care to the residents on contact and droplet precautions. […]

• No harm, potential for more than minimal, isolatedF604Apr 6, 2026

  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. […]