Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coler Rehabilitation And Nursing Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and severe cognitive impairment was observed in bed with two large body-sized pillows secured under the bedsheet on both sides, making them unable to be removed by the resident. Staff stated the pillows were being used because the resident banged on side rails and tried to get out of bed, but there was no clear physician order for two pillows, no documented ongoing reassessment, and the care plan and PT review addressed only a single comfort pillow or general positioning device.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in a femoral fracture. The facility did not report the injury to the Department of Health within the required timeframe after learning of the fracture, instead delaying the report until the following day, contrary to regulatory requirements.
A resident with severe cognitive impairment experienced multiple falls due to inadequate supervision in an LTC facility. Despite being on a two-hour monitoring schedule, the resident was found on the floor several times, including an incident where they sustained a bruise and skin abrasion. The care plan was not effectively modified to prevent these falls, and staff interviews revealed that monitoring frequency was not adjusted appropriately.
A resident with cognitive impairment and a feeding tube was reportedly restrained by a nurse during medication administration, resulting in a scratch mark. The resident claimed their arm was tied to the bedrail with a plastic bag after refusing medication, but the nurse denied using the bag for restraint. The facility's investigation was inconclusive due to a lack of evidence and witnesses.
A resident with paraplegia and chronic pain alleged that a Food Service Aide hit their leg with a food truck. Despite the incident, the resident's care plan was not reviewed or updated as required by facility policy. The facility's investigation did not support the abuse allegation, but the care plans addressing risks for abuse and behavior problems were not revised. Staff interviews revealed confusion about responsibility for updating the care plan.
Unordered body pillows used as a restraint without reevaluation
Penalty
Summary
The facility failed to ensure that a resident was free from the use of a physical restraint that was not documented as required for medical treatment and failed to document ongoing reevaluation of the restraint. Resident #216 had diagnoses including Alzheimer’s Disease and Depression, and the Quarterly MDS documented severe cognitive impairment, daily physical behavioral symptoms toward others, and daily behavioral symptoms not directed toward others. The assessment also documented that the resident did not use restraints while in bed, despite later observations showing two large body-sized pillows positioned under the bedsheet on both sides of the resident. On observation, Resident #216 was awake in bed with upper half side rails raised on both sides and two large body-sized pillows secured between the bedsheet and mattress, extending from the resident’s head to ankles. The pillows could not be removed by the resident while in bed. Staff stated the resident had a history of attempting to get out of bed at night and banging on the side rails, and that the pillows were being used after the family requested full bilateral side rails and the resident began banging on the rails. Registered Nurse #3 stated the pillows were believed to have been placed under an order for a wedge cushion, but that the order should have specified where to place the cushions, how many were to be used, and the indication for use. Record review showed a Rehabilitation Referral Form that addressed consideration of a positioning device such as a long pillow or body aligner and recommended a body aligner for positioning and pressure relief, but it did not address the placement of the pillows secured under the bedsheet or the use of two pillows. The care plans for behavior and activities of daily living did not reference the two large body-sized pillows as an intervention, and the bed mobility intervention referenced upper side rails but did not address the pillows. Facility staff, including the Head Nurse, Deputy DON, Director of Rehabilitation, PT Supervisor, Medical Director, and Quality Management Director, stated that the use of the pillows should have had a physician’s order, quarterly assessments, and care planning, and that the assessment completed for one pillow did not establish the safety of two pillows or their placement under the bedsheet.
Failure to Timely Report Serious Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving a resident who experienced an unwitnessed fall resulting in a left femoral fracture. According to facility policy and regulatory requirements, all allegations of abuse, neglect, or injuries of unknown source that result in serious bodily injury must be reported to the New York State Department of Health immediately, but not later than two hours after the facility becomes aware. In this case, the resident, who had severe cognitive impairment and required supervision and assistance with mobility, was found on the floor near their bed in pain and holding their left thigh. The resident reported to staff that they had rolled off the bed and fallen, and was subsequently sent to the hospital where a left femoral fracture was diagnosed. Despite the facility becoming aware of the injury upon the resident's return from the hospital, the incident was not reported to the Department of Health until the following day, exceeding the required reporting timeframe. Interviews with facility leadership confirmed that the injury should have been reported within two hours of the facility learning about the fracture, but the report was delayed until confirmation of the injury was received. This delay in reporting did not comply with both facility policy and state regulations regarding the timely reporting of serious injuries of unknown origin.
Inadequate Supervision Leads to Repeated Falls
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident, as evidenced by multiple falls. The resident, who had severe cognitive impairment and a history of falls, was found on the floor next to their bed on several occasions throughout the year. Despite being on a two-hour monitoring schedule, the resident continued to experience falls, indicating that the supervision and interventions in place were insufficient to prevent these incidents. On the evening of December 2, 2024, the resident was found on the floor with a bruise and a skin abrasion below their right eye. The resident was subsequently transferred to the hospital for further evaluation. The care plan for the resident had been updated multiple times following previous falls, but there was no documented evidence of modifications to the monitoring schedule or care plan after each incident, which contributed to the repeated falls. Interviews with staff revealed that the resident was positioned in bed with the call bell within reach, but the monitoring frequency was not adjusted to address the resident's ongoing risk of falls. The Associate Director of Nursing acknowledged that the monitoring should have been increased to every 30 minutes, but this change was not implemented. The lack of timely and effective modifications to the resident's care plan and monitoring schedule led to the deficiency in providing adequate supervision to prevent accidents.
Plan Of Correction
Plan of Correction: Approved January 21, 2025 What corrective actions(s) will be accomplished for the resident found to have been affected by the deficient practice? I. The following actions were accomplished for those residents found to have been affected by the deficient practice: The affected resident’s (Resident #1) care plan was modified/updated to include monitoring q30 minutes. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: The facility will conduct a review of residents with a history of two or more falls over the past six months to identify those who may require more frequent monitoring to minimize the risk for falls. DNS or designees will conduct an audit on residents who have a history of two or more falls in the past six months. The audit will ensure that a new fall risk evaluation is completed, and that the care plan is revised and updated to reflect modifications to frequency of monitoring, if applicable. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur; III. The following system changes will be implemented to ensure that the deficient practice does not recur: The facility's policy and procedure PC67, titled Fall Reduction and Injury Prevention Program, has been reviewed. It has been determined that no revisions are necessary at this time. All active nursing staff will be re-in-serviced on the Fall Prevention policy by the Nursing Educator(s). All active licensed registered nursing staff will be re-educated on updating residents’ plans of care to include modifications in monitoring frequency, as applicable. An audit tool has been developed to systematically monitor the completion of post-fall risk evaluations, updates to care plans, and, where applicable, modifications to the monitoring frequency. How the corrective actions(s) will be monitored to ensure deficient practice will not recur, i.e., what quality assurance program will be put into practice IV. The facility’s compliance will be monitored utilizing the following quality assurance system: DNS or designee will report assessment results for residents who have a history of two or more falls in the past six months to the Quality Assurance Performance Improvement (QAPI) committee to ensure compliance with post-fall assessments, care plans, and monitoring. The completion of staff education and compliance with post-fall assessments, care plans, and monitoring will be reported to the Quality Assurance Performance Improvement (QAPI) committee weekly for one month and then monthly for three months, or until compliance is achieved. Responsible Person: Yves Pascal, Director of Nursing
Resident's Right to Be Free from Physical Restraint Violated
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraint, as evidenced during a medication administration incident involving a registered nurse and a resident with a history of epilepsy, traumatic brain injury, and chronic respiratory failure. The resident, who had moderate cognitive impairment and a feeding tube, was reportedly restrained by the nurse during the administration of medication. The nurse held the resident's right arm firmly after the resident swung their arm, resulting in a scratch mark on the resident's right hand. The resident claimed that the nurse tied their arm to the bedrail with a plastic bag after they refused medication, although the nurse denied using the bag for restraint. The facility's policies on abuse prevention and restraint use were not adhered to, as the incident involved the use of a physical restraint without medical justification. The facility's investigation into the incident was inconclusive, with the risk manager and administrator stating that the abuse allegation was undetermined due to a lack of evidence and witnesses. The incident was documented in various reports, including a physician's progress note and an accident/incident report, which highlighted discrepancies between the resident's account and the nurse's statement.
Failure to Update Care Plan After Allegation of Abuse
Penalty
Summary
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 deficiency was identified during an Abbreviated Survey, where it was found that a resident alleged that a Food Service Aide hit their leg with a food truck. Despite the incident, the resident's Comprehensive Care Plan was not reviewed or updated to reflect the allegation. The facility's policies require that care plans be reviewed and revised following incidents of abuse, but this was not done in this case. The resident involved had diagnoses of paraplegia, chronic pain, and diabetes mellitus, and was cognitively intact. The incident occurred when the resident became agitated after a disagreement with the Food Service Aide regarding the placement of their food tray. The facility's investigation concluded that the evidence did not support the allegation of staff-to-resident abuse. However, the care plans for the resident, which included risks for abuse and behavior problems, were not reviewed or updated after the incident. Interviews with facility staff revealed confusion about who was responsible for updating the care plan, with different staff members attributing the responsibility to others.
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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.
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Nursing homes near Roosevelt Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mary Manning Walsh Nursing Home Co Inc | 0.7 mi | ★★★★★ | 3 | 0 |
| Upper East Side Rehabilitation And Nursing Center | 1.5 mi | ★★★★★ | 2 | 0 |
| New York Center For Rehabilitation & Nursing | 1.9 mi | ★★★★★ | 0 | 0 |
| Terence Cardinal Cooke Health Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Queens Boulevard Extended Care Facility | 2.7 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 August 2026) and official state health department websites.