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Deficiency Records for Cold Spring Hills Center For Nursing and Rehab

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.

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?
Protect each resident from the wrongful use of the resident's belongings or money. Health 2024-05-16 2024-05-31 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-04 2024-03-21 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2024-03-04 2024-03-21 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-02-12 2024-03-01 Y
Use approved construction type or materials. Fire Safety 2023-08-11 2024-01-26 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-08-11 2024-01-26 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2023-08-11 2024-01-26 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 2024-01-10 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-08-11 2024-01-09 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-08-11 2023-12-30 N
Have proper power supply for life support equipment. Fire Safety 2023-08-11 2023-12-28 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-08-11 2023-12-27 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-08-11 2023-11-13 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-08-11 2023-11-13 N
Meet other general requirements. Fire Safety 2023-08-11 2023-10-10 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2023-08-11 2023-10-10 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-08-11 2023-10-10 N
Have an enclosure around a vertical opening shaft. Fire Safety 2023-08-11 2023-10-10 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 2023-10-10 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2023-08-11 2023-10-10 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 2023-10-10 N
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 properly protected cooking facilities. Fire Safety 2023-08-11 2023-09-30 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-08-11 2023-09-30 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-08-11 2023-09-30 N
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
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
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

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