Coldspring Transitional Care Center

Based on interview, record review, review of the facility's investigation, review of the nursing guidebook of professional standards, review of the Kentucky Board of Nursing (KBN) standards, and review of the facility's policies, the facility failed to ensure nursing services provided met professional standards of practice for 1 out of 12 sampled residents, Resident (R) 1.R1 was administered incorrect medications on 09/10/2025, which caused her to be sent to the hospital for further evaluation on 09/10/2025.Based on review of the facility's plan of correction (PoC) and validation through observation, interviews, and record reviews, the facility had implemented corrective actions with a compliance date of 09/18/2025, before survey entrance. Therefore, the deficient practice was past noncompliance.The findings include: Review of the facility's policy titled, Identification of the Resident Prior to Medication Administration, revised 12/2021, revealed, Prior to administering medication, the nurse/medication aide identifies the recipient of the medication by: asking the resident his/her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility's policy, the facility failed to provide a nourishing snack at bedtime for 9 of 9 residents, Resident (R) 7, R22, R36, R66, R68, R76, R81, R91, and R94. On 05/13/2025 at 3:16 PM during the Resident Council meeting, all residents present stated the facility did not provide nourishing snacks for residents at bedtime. The findings include: Review of the facility's policy titled, [Facility] Health Care Management Nourishment Center, dated 06/2019, revealed the facility would have light refreshments/snacks available to residents between meals or over-night. Per the policy, the refreshments would be available to new residents arriving to the facility after the evening meal. Observation during the initial tour on 05/12/2025 between 6:14 PM and 10:07 PM revealed State Tested Nursing Aides (STNA) on the 1300 Unit and 1400 Unit were asking residents if they wanted ice but did not inquire to see if the residents needed snacks. During an interview on 05/13/2025 at 3:16 PM in the Resident Council meeting, all residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 32 sampled residents, Resident (R) 122, in Transmission-Based Precaution (TBP) or Enhanced Barrier Precautions (EBP). 1. Observation and interview on 05/12/2025 revealed State Tested Nurse Aide (STNA) 2 provided direct care to R122 who was under EBP. The STNA did not don (put on) Personal Protective Equipment (PPE) before providing direct care. STNA2 was observed to exit R122's room wearing gloves while transporting trash to the dirty utility room. 2. Observation and interview on 05/12/2025 revealed Licensed Practical Nurse (LPN) 4 used a portable vital sign machine on R142 who was in EBP. The LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, the facility failed to provide a homelike environment free of odors for 1 of 8 hallways, the 2100 Hall, with a census of 15 residents. The findings include: Review of the facility's policy titled, Environmental Services- Homelike Environment, dated 01/2025, revealed the facility was to provide a clean, odor free facility. Observations on 05/12/2025 at 6:55 PM and 8:27 PM, 05/13/2025 at 3:38 PM and 4:16 PM, and 05/14/2025 at 10:31 AM, revealed a strong urine smell in the 2100 hall, particularly concentrated around Resident (R) 79's room. Continued observation on 05/15/2025 at 10:58 AM revealed the odor of urine was still present, although not as strong as the previous days. In an interview on 05/12/2025 at 6:57 PM, R79 stated he spilled a full urinal by accident earlier that day, and it was a while before staff cleaned it up. He explained staff had not emptied his urinal after the last time he used it, and he did not realize that it had urine in it when he first picked it up. In an interview on 05/15/2025 at 11:05 AM, State…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set [MDS] assessments were correct for 1 of 32 sampled residents, Resident (R) 45. The findings include: Review of R45's admission Record revealed the facility admitted the resident on 11/19/2022 with admission diagnoses including Parkinson's disease, Alzheimer's disease, and protein-calorie malnutrition. Review of R45's Comprehensive Care Plan (CCP), not dated, revealed the facility assessed the resident as having a self-care deficit related to range of motion limitations and contractures of her knees. Further review revealed interventions including use of a Broda chair (special adaptive wheelchair), use of a Hoyer lift (mechanical lift to transfer the resident from surface to surface), and assisting with positioning to help maintain proper body alignment. Review of R45's quarterly MDS, with an Assessment Reference Date (ARD) of 03/07/2025, and the quarterly MDS, with an ARD of 05/08/2025, revealed the facility coded R45 as having no impairment in functional range of motion in her upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility's Policy, it was determined the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Observations on 01/28/2020, 01/29/2020, 01/30/2020, and 01/31/2020, revealed the 1200 Unit Hallway had a strong odor of urine. The findings include: Review of the facility's Policy titled, Guidelines to Good Housekeeping - Environmental Services Nursing Department, dated 02/28/03, revealed it was the policy of the facility to provide guidelines specific for cleaning duties to provide an optimum environment for the staff, residents, and visitors. Continued review revealed the procedure for cleaning included for the resident lavatory to be sprayed with an EPA approved disinfectant and wiped with a damp cloth, clean the inside surfaces of the bowl, rinse the cloth under the faucet and rinse the inner surfaces of the bowl and wash and rinse the outer surfaces of the bowl with a damp cloth. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to implement the Comprehensive Person-Centered Care Plan for each resident to assist in attaining or maintaining the residents' highest practicable quality of life for one (1) of twenty-six (26) sampled residents, (Resident #109). Resident #109 had a Vascular Access Catheter for Hemodialysis on the left upper chest at the Subclavian region due to previous Hemodialysis due to End Stage Renal Disease. The Vascular Access was exposed and did not have a wound covering/dressing in place. The findings include: Review of facility's Care Planning Policy, dated 01/2019, revealed the facility will provide resident centered care aiming to provide individualized Comprehensive/Interdisciplinary Care Plans for each resident. The care plan is developed to guide the resident in reaching their maximum functional level -while encompassing a holistic approach. The facility's objective is to assist the resident in meeting their personal goals, with optimal functioning level and a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities for one (1) of twenty-six (26) sampled residents (Resident #53). An Audiology (hearing) evaluation performed by Three Sixty (360) Care, on 03/05/2019, determined Resident #53 would benefit from hearing aids to help his/her hearing loss. The recommendation was sent to the attending physician for approval on 03/05/2019. The facility received signed approval from the attending physician on 03/11/2019. However, there was no documented evidence the facility followed through with assisting Resident #53 in making follow up appointments with Three Sixty (360) Care. Consequently, Resident #53 did not receive hearing aids as recommended. The findings include: A post-survey phone interview, with the Administrator, on 02/07/2020 at 11:15 AM, revealed the facility does not have a policy regarding hearing exams. Record review revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe sanitary and comfortable environment to help prevent the development and transmission of communicable diseases infections for one (1) of twenty-six (26) sampled residents (Resident #109) Observation on 01/29/2020 during the initial screening interview revealed Resident #109 had a vascular access catheter located at the left clavicle-chest area which was exposed without a dressing in place. This access had been utilized for dialysis. The findings include: Review of the facility's Policy, titled Infection Prevention and Control (IPCP), revised 01/2020, revealed the tended purpose of the facility's infection control policy was to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Continued review revealed all personnel would be trained on the infection control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation on 01/16/18, revealed three (3) medication carts had boxes of foiled packages of ipratropium/albuterol nebulizer vials. The foiled packages were open and expired, or were open and not marked with an open date. The findings include: Review of the facility Medication storage Policy, dated 8/2018, revealed once a medication is opened the facility should follow manufacturer/supplier guidelines with respect to expiration dates related to opened medications. Continued review revealed facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Further review of the Policy, revealed medications and biologicals should not be retained longer than recommended by manufacturer or supplier. Review of the Manufacturer's Recommendations for ipratropium/albuterol nebulizer vials, revealed once the foiled packaging was open, discard after fourteen (14) days.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for one (1) of thirty-three (33) sampled residents (Resident #1). Although Resident #1 sustained falls on 11/04/18, 12/08/18, and 12/10/18, and record review revealed interventions were implemented after the falls; there was no documented evidence the Comprehensive Care Plan (CCP) was revised with these interventions. Also, Physician's Orders were received on 01/09/19 for fall interventions; however, the CCP was not revised to include these orders/interventions. The findings include: Review of the facility's Policy titled Advance Care Planning, revised 12/2017, revealed it was the facility's policy that situations needing investigation and/or follow up are conducted timely. However, the Policy did not address revision of the Care Plan. Review of the facility's Fall and Accident Management Policy, revised 05/2016, revealed when a resident falls the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.