Deficiency Records for Cold Spring Hills Center For Nursing and Rehab
Updated as of April 01, 2024
A list of the most recent deficiencies for Cold Spring Hills Center For Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-10 | 2023-10-09 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2023-08-10 | 2023-10-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-10 | 2023-10-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-10 | 2023-10-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-10 | 2023-10-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-10-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-10 | 2023-10-01 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-08-10 | 2023-10-01 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-10 | 2023-09-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-10 | 2023-09-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-10 | 2023-09-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-10 | 2023-09-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-10 | 2023-09-30 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-08-10 | 2023-09-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-10 | 2023-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-10 | 2023-09-15 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-08-10 | 2023-09-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-08-10 | 2023-09-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-10 | 2023-09-15 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-10 | 2023-09-01 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-05-09 | 2022-05-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-22 | 2022-01-20 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-10-29 | 2021-12-01 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-24 | 2021-07-23 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-05-24 | 2021-07-23 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-05-24 | 2021-07-23 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-24 | 2021-06-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-24 | 2021-06-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-24 | 2021-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-24 | 2021-06-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-24 | 2021-06-30 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2021-05-24 | 2021-06-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-24 | 2021-06-30 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-05-24 | 2021-06-30 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-14 | 2020-02-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-14 | 2020-02-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-14 | 2020-02-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-14 | 2020-02-27 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2020-01-14 | 2020-02-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-11 | Not Fixed | N |
| Meet other general requirements. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Use approved construction type or materials. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-11 | Not Fixed | N |
| Use approved construction type or materials. | Fire Safety | 2021-05-24 | Not Fixed | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-14 | Not Fixed | N |
