Cold Spring Hills Center for Nursing and Rehabilitation: Violations and Inspection History

State Inspections Reveal 56 Health Code Violations (2018–2021)

Cold Spring Hills Center for Nursing and Rehabilitation has received 56 citations for violations of public health code between 2018 and 2021, according to New York State Department of Health records accessed on February 4, 2022. The facility has also received three fines totaling $24,000 since 2015. The Woodbury nursing home’s citations resulted from a total of 14 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure resident environments are “as free of accident hazards as is possible.” A May 2021 citation found that Cold Spring Hills Center for Nursing and Rehabilitation failed to ensure such. The citation specifically describes an instance in which a resident, identified as at risk of elopement and wearing a wander guard device, used an elevator to reach the facility’s lobby without the wander guard activating the elevator door. After this incident, the citation states, a registered nurse supervisor “did not report the elevator door malfunction,” and a few months later the resident again reached the facility lobby via the elevator. In a second instance described by the facility, a resident’s wheelchair had a “broken removable right arm rest” identified by staff but not addressed until several days after its identification. A plan of correction undertaken by the facility included the education of relevant staff. 
2. The nursing home did not adequately prevent the use of unnecessary drugs. Under Section 483.45 of the Federal Code, residents have a right to be free from the unnecessary use of psychotropic medications. A May 2021 citation found that Cold Spring Hills Center for Nursing and Rehabilitation failed to ensure such. The citation specifically describes a resident prescribed an antipsychotic medication whose dosage was doubled “without documented evidence of the justification for the increase.” A plan of correction undertaken by the facility included a dose reduction and counseling of the nurse who wrote the order for an increased dosage.
3. The nursing home did not adequately prevent medication errors. Section 483.45 of the Federal Code ensures nursing home residents the right to be “free of any significant medication errors.” An October 2019 citation found that Cold Spring Hills Center for Nursing and Rehabilitation failed to ensure such. The citation states specifically that one resident experienced medication errors in a case in which “there was no documented evidence that the resident received” certain medications they were prescribed, and “no evidence documenting the physician was informed of the unavailability of the medications.” In an interview, the facility’s Director of Nursing Services said that “the medication was not available, either because it was entered in the system too late to receive from the pharmacy or the medication was not available in the emergency supply.” A plan of correction undertaken by the facility included the counseling of relevant staff.

State Inspections Reveal 24 Health Code Violations (2016–2020)

Cold Spring Hills Center for Nursing and Rehabilitation received 24 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 27, 2020. The facility has also been the subject of a 2016 fine of $12,000 in connection to findings during a 2015 inspection that it violated health code provisions regarding quality of care and staff mistreatment of residents; and a second 2016 fine of $10,000 in connection to findings during a 2015 inspection that it violated health code provisions regarding accidents. The Woodbury nursing home’s citations resulted from a total of 11 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate pressure ulcer treatment and care. Section 483.25 of the Federal Code requires nursing homes to ensure residents receive necessary treatment and services to promote the healing of pressure ulcers and the prevention of new ulcers from developing. A September 2019 citation found that Cold Spring Hills Center for Nursing and Rehabilitation did not ensure such for one resident. The citation states specifically that a pressure ulcer identified by the resident on September 20, 2018 was not assessed by a Registered Nurse until September 23, 2018. The citation states further that the RN in question “initiated treatment without a physician’s orders,” and that the lack of a pressure ulcer assessment resulted in “actual harm” to the resident.
2. The nursing home did not ensure an environment free of accident hazards. Section 483.25 of the Federal Code requires nursing homes to maintain resident environments “as free of accident hazards as is possible.” A June 2016 citation found that Cold Spring Hills Center for Nursing and Rehabilitation did not maintain such. The citation found specifically that the facility had no “written safety plan in place during roof repairs,” resulting in leaks as well as the potential for leaks in resident rooms in one unit. The citation states further that the facility had no “safety checklist in place during the renovation work.” The nursing home’s Assistant Administrator stated in an interview that “he would develop and implement a written safety plan and checklist for the rest of the roof repairs.”
3. The nursing home failed to ensure residents were not administered unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing home facilities must keep “each resident’s drug regimen… free from unnecessary drugs.”A May 2016 citation found that Cold Spring Hills Center for Nursing and Rehabilitation did not ensure a resident’s drug regimen was free from such. The citation states specifically that the resident was ordered and administered a redacted anxiety medication even though there was “no documented evidence of non-pharmacological interventions attempted prior to the administration” of that medication. According to the citation, this deficiency had the “potential to cause more than minimal harm.

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