Coldspring Transitional Care Center

In the surveyor’s words

From the most serious findings on record at Coldspring Transitional Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF809May 15, 2025

  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. […]

• No harm, potential for more than minimal, patternF880May 15, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF689Jun 26, 2026

  Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the environment remained free of accident hazards as much as possible for 2 of 37 sampled residents, Resident (R) 54 and R116. Observation of the shared bathroom for R54 and R116 on 06/23/2026 at 11:43 AM revealed a white powdery substance in an unlabeled medication cup sitting on the bathroom sink. The findings include: Review of the facility's policy titled, Fall and Accident Management, revision date 06/2019, revealed the facility would identify patients at risk of falls and other accidents with implementations placed and evaluated to reduce risk of injuries, falls or other accidents. […]

• No harm, potential for more than minimal, isolatedF658Nov 24, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF584May 15, 2025

  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. […]