Coler Rehabilitation and Nursing Care Center

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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)

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.