COLD SPRINGS HILLS CTR FOR NURSING AND REHAB

Nursing Home Inspector

378 SYOSSET WOODBURY ROAD
WOODBURY, NY 11797
Nassau County
Phone: 516-921-3900
Provider Number: 335555
Last Inspection: 06/21/2017

About the Nursing Home

Number of Beds: 606
Number of Residents: 541
Beds Available: 65
Percent Occupancy: 89%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

26

Facility
12

County
14

NY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

26

2017
24

2016
27

2015
4

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

6/21/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 8/11/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 8/11/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 8/11/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 8/11/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 8/11/2017
 
Failed To: Keep all essential equipment working safely. Pattern : Potential 3 8/11/2017
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Isolated : Minimal 3 8/11/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 8/11/2017
 

5/13/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 7/11/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 7/11/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 7/11/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 7/11/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 7/11/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 7/11/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 7/11/2016
 

6/19/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 8/17/2015
 

6/15/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 8/14/2015
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 8/14/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 8/14/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 8/14/2015
 
Failed To: Allow residents to self-administer drugs if determined safe. Isolated : Minimal 3 8/14/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 8/14/2015
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 8/14/2015
 
Failed To: Provide housekeeping and maintenance services. Isolated : Minimal 3 8/14/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 8/14/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

11/16/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 1/13/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 1/13/2017
 

6/29/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 8/30/2016
 

11/18/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 1/16/2016
 

11/13/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 1/11/2016
 

11/5/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 1/7/2016
 
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Actual 4 4/11/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 1/7/2016
 

6/19/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 8/17/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NY State Avg
Number of Residents 541 181.05 167.28
Registered Nurses 0.72 0.86 0.74
Licensed Practical / Vocational Nurses 0.83 0.74 0.84
Certified Nursing Assistants 2.52 2.45 2.30
Total Staff Hours 4.07 4.06 3.88

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NY State Avg%
of high risk long-stay residents with pressure ulcers 9 8 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 87 97 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 94 97 96
of long-stay residents experiencing one or more falls with major injury 1 1 2
of long-stay residents who have depressive symptoms 55 9 8
of long-stay residents who lose too much weight 5 6 6
of long-stay residents who received an antianxiety or hypnotic medication 14 16 15
of long-stay residents who received an antipsychotic medication 11 11 13
of long-stay residents who self-report moderate to severe pain 1 1 3
of long-stay residents who were physically restrained 1 0 0
of long-stay residents whose ability to move independently worsened 9 12 16
of long-stay residents whose need for help with daily activities has increased 8 9 13
of long-stay residents with a catheter inserted and left in their bladder 1 1 1
of long-stay residents with a urinary tract infection 2 2 3
of low risk long-stay residents who lose control of their bowels or bladder 37 49 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 57 88 81
of short-stay residents who had an outpatient emergency department visit 7 8 9
of short-stay residents who made improvements in function 58 64 68
of short-stay residents who newly received an antipsychotic medication 2 1 1
of short-stay residents who self-report moderate to severe pain 5 4 9
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 72 86 82
of short-stay residents who were rehospitalized after a nursing home admission 17 21 21
of short-stay residents who were successfully discharged to the community 56 50 48
of short-stay residents with pressure ulcers that are new or worsened 0 0 0