Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coldspring Transitional Care Center during CMS and state inspections, most recent first.
A nurse gave a resident another resident’s pre-pulled meds during morning med pass after leaving the cart to respond to yelling in the hall. The resident, who had Alzheimer’s disease and other chronic conditions, was found with altered mental status and low O2 sat, received oxygen and Narcan, and was sent to the ER after the error was reported.
The facility did not provide nourishing snacks at bedtime to multiple residents, including those with diabetes and other medical conditions, despite having a policy requiring snacks to be available overnight. Staff interviews indicated that snacks were supposed to be offered and available at all times, but residents reported not being offered snacks at bedtime, and observations confirmed that aides only offered ice in the evenings.
Staff failed to consistently follow infection prevention and control protocols, including not wearing required PPE during high-contact care, not performing hand hygiene, and not cleaning shared equipment after use for a resident under Enhanced Barrier Precautions. Interviews revealed gaps in staff knowledge of facility policy and CDC guidelines, and observations showed improper storage of PPE and lack of formal compliance audits.
A persistent urine odor was noted in one hallway, concentrated near a resident's room, due to repeated urinal spills and soiled briefs left on the floor. Despite regular cleaning by nursing and housekeeping staff, the odor remained, with staff attributing the issue to urine having soaked into the flooring materials, making standard cleaning ineffective.
A resident with Parkinson's disease, Alzheimer's disease, and protein-calorie malnutrition was inaccurately coded on two quarterly MDS assessments as having no range of motion impairments, despite documented contractures in the knees and left hand. Observations and staff interviews confirmed the inaccuracies, with staff attributing the errors to incorrect coding and lack of direct assessment.
Wrong Medications Given During Medication Pass
Penalty
Summary
The nursing facility failed to ensure nursing services met professional standards of practice when a nurse administered the wrong medications to a resident during morning medication pass. The resident had been admitted with diagnoses including Alzheimer’s disease, chronic pain, anxiety, atrial fibrillation, and hypertension, and the quarterly MDS showed a BIMS score of 13 out of 15, indicating intact cognition. The resident was given medications intended for another resident, including oxycodone-acetaminophen 5/325 mg, clonazepam 0.5 mg, nifedipine ER 30 mg, vitamin B12 1000 mcg, iron 325 mg, and omeprazole 40 mg. According to the nurse’s interview, she was preparing medications for one resident when another resident began yelling. She left the medication pass, went to check on the resident who was yelling, and had already pulled the first resident’s medications and placed them in a cup in her cart. She then gave those medications to the wrong resident by mistake. She stated she realized the error right away and reported it. The resident was assessed, found to have altered mental status, and vital signs were obtained showing blood pressure 148/90, pulse 62, respirations 20, temperature 97.6 axillary, and oxygen saturation 88% on room air. Oxygen was applied and Narcan was given, after which oxygen saturation increased to 96%. The incident investigation documented that the physician was notified and the resident was sent to the ER for further evaluation. The resident’s son was also notified. The resident was admitted to the hospital related to pneumonia and CHF. The nurse stated she should have continued with the original resident’s medication administration and made the other resident wait until she was finished. Interviews with the resident’s representative confirmed the facility reported the medication error and transfer to the ER, and the representative stated the resident had never previously received the wrong medications.
Failure to Provide Bedtime Nourishing Snacks to Residents
Penalty
Summary
The facility failed to provide nourishing snacks at bedtime for all nine residents reviewed, despite having a policy that required light refreshments or snacks to be available between meals and overnight. Observations during the initial tour revealed that State Tested Nursing Aides (STNAs) were only offering ice to residents in the evening and did not inquire about snacks. During a Resident Council meeting, all residents present confirmed that they had not been offered snacks at bedtime. Several residents had medical conditions that made access to snacks particularly important, including diabetes mellitus, morbid obesity, and major depressive disorder. For example, one resident reported needing snacks to manage blood sugar levels due to insulin use, and another described experiencing symptoms of hypoglycemia and resorted to keeping snacks in her room because she could not rely on staff to provide them. Multiple residents were assessed as cognitively intact, while others had moderate cognitive impairment, indicating a range of abilities to request or obtain snacks independently. Interviews with staff, including STNAs, the Executive Chef, the DON, and the Administrator, revealed inconsistencies in the process for offering snacks. While staff stated that snacks were available 24/7 and that aides were responsible for offering them, residents reported not being offered snacks at bedtime. The facility's policy and staff expectations were not consistently followed, resulting in residents not receiving nourishing snacks as required.
Failure to Maintain Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices among staff caring for residents under Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). Direct care staff, including State Tested Nurse Aides (STNAs) and Licensed Practical Nurses (LPNs), were observed providing care to residents without donning required personal protective equipment (PPE) such as gowns and gloves, despite facility policy and CDC guidelines mandating their use during high-contact activities. In several instances, staff exited resident rooms wearing contaminated gloves, transported trash without removing gloves or performing hand hygiene, and failed to clean and disinfect shared equipment such as Hoyer lifts and portable vital sign machines after use. Interviews with staff revealed a lack of understanding and inconsistent knowledge regarding the facility's infection control policies, particularly concerning the requirements for PPE use under EBP. Some staff members were unable to explain the meaning of EBP or the specific circumstances under which gowns and gloves were required. Residents reported that staff routinely failed to wear gowns during direct care activities, including assistance with bedpans and wound care, even when PPE was available in the room. Additionally, observations showed that PPE was not always stored in a sanitary manner, with clean gowns found on the floor outside isolation rooms. Leadership interviews indicated that while staff received initial and ongoing training on infection prevention and control, there were no formal audits in place to monitor compliance. The Infection Preventionist and Director of Nursing acknowledged expectations for adherence to CDC guidelines and facility policy but were unable to account for the observed lapses in practice. The cumulative effect of these actions and inactions resulted in a failure to provide a safe, sanitary, and comfortable environment and did not prevent the development and transmission of communicable diseases and infections among residents.
Persistent Urine Odor Due to Inadequate Environmental Management
Penalty
Summary
The facility failed to maintain a homelike, odor-free environment as required by its policy, specifically in the 2100 Hall where a persistent urine odor was observed over several days. Multiple observations documented a strong urine smell concentrated around one resident's room, with the odor persisting despite cleaning efforts. The resident reported accidentally spilling a full urinal, which was not promptly cleaned, and noted that staff had not emptied the urinal after its last use. Staff interviews confirmed that urine spills and odors were a frequent issue in this area, with both the resident and his roommate regularly using urinals that sometimes spilled and leaving soiled briefs on the floor. Housekeeping and nursing staff described a process where nursing would clean the initial spill and notify housekeeping for further cleaning, including deep cleaning twice weekly. Despite these efforts, the odor remained, and the Regional Housekeeping Manager determined that the urine odor had likely penetrated the flooring materials, making it difficult to eliminate with standard cleaning. The Administrator acknowledged awareness of the persistent odor and attributed it to repeated urine spills soaking into the floor, indicating that the flooring may need replacement to fully resolve the issue.
Inaccurate MDS Assessments for Resident with Documented Contractures
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for one resident. The resident was admitted with diagnoses including Parkinson's disease, Alzheimer's disease, and protein-calorie malnutrition, and was assessed as having self-care deficits related to range of motion limitations and contractures of her knees. Despite these documented limitations, the quarterly MDS assessments coded the resident as having no impairment in functional range of motion in both upper and lower extremities. Observations confirmed the presence of bilateral knee contractures and a contracture in the left hand, with adaptive equipment and instructions for use present in the resident's room. Interviews with facility staff revealed that the MDS nurse primarily relied on nursing assessments and the care plan, and did not consistently perform direct assessments of the resident. The MDS Coordinator and DON acknowledged that the MDS assessments were inaccurate, attributing the errors to incorrect coding or misunderstanding of the assessment questions by the responsible nurse. The administrator was unaware of the specific cause of the error but expected assessments to be accurate.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cold Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Seasons At Alexandria | 1.9 mi | ★★★★★ | 6 | 1 |
| Carmel Manor | 4.3 mi | ★★★★★ | 15 | 0 |
| Rosedale Green | 4.6 mi | ★★★★★ | 0 | 0 |
| Highlandspring Of Ft Thomas | 5.3 mi | ★★★★★ | 3 | 0 |
| Residence At Salem Woods | 5.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.