Rainbow Terrace Care Center

Based on record review and interview, the facility failed to electronically submit direct care staffing data based on the facility payroll to CMS. The Resident Census and Conditions of Residents form documented 27 residents reside in the facility. Findings: The Quality Improvement and Evaluation System was reviewed and did not reveal PBJ data for the facility during the previous two quarters. On 08/21/23 at 9:46 a.m., an interview was conducted with the BOM, and they were not aware of a staffing report needing to be submitted to CMS for direct care for residents. They also stated the only care report they needed to complete was the quality of care for the state. The BOM stated the administrator was probably doing these reports, but he has been out of the facility with health issues. On 08/21/23 at 9:50 a.m., the acting administrator was not currently available for an interview. On 08/22/23 at 10:27 a.m., the acting administrator was not currently available for an interview. On 08/22/23 at 10:29 a.m., an interview was conducted with the DON and they stated the administrator, nurse…

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 record review and interview, the facility failed to assess a resident for an infection using standardized tools and criteria for the initiation of an antibiotic for one (#105) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 08/15/23, documented no residents were currently receiving antibiotics. Findings: The care plan, dated 08/14/22, documented the resident was a high risk for UTI's due to catheter and urine backflow. The care plan documented to monitor/document/report to the physician as needed for signs and symptoms of UTI such as frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea , vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, and behavioral changes. The most recent assessment, dated 08/29/22, documented the resident was not impaired for daily decision making, was independent with most ADLs, and had not received an antibiotic the past seven days. A physician order, dated 07/20/23, documented Bactrim DS BID for 14…

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 record review and staff interview, it was determined the facility failed to provide staff training over behavioral health issues. The Resident Census and Conditions of Residents form documented 27 residents reside in the facility. Findings: An Abuse Prevention Program policy read in part, .Required staff training/orientation programs that includes such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior .Handling verbally and physically aggressive residents behavior. On 09/12 23 at 12:50 p.m. an observation was made of [NAME] #1's employee file and the file only had an application for employment in it. a. LPN #2; hire date 07/16/23, b. [NAME] #1; hire date 08/08/23, c. [NAME] #2; hire date 08/26/21, d. DA #1; hire date 04/28/23, and e. DA #2; hire date 09/17/20. On 09/12/23 at 9:55 a.m.,an interview was conducted with the SS/BOM, they stated they did not provide training/orientation for verbally and physically aggressive resident behaviors for the five employees upon hire.…

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, record review, and interview, the facility failed to provide an advance directive acknowledgment for one (#101) of four residents reviewed for advance directives. The Resident Census and Condition of Residents, documented a census of 27 residents. Findings: Res #101 admitted to the facility on [DATE] and had diagnoses which included major depressive disorder, psychotic disorder, and dementia. An admission assessment, dated [DATE], documented the resident was moderately impaired with cognition and was independent with most ADLs. The assessment documented the resident had delusions and received antipsychotic and antianxiety medication. On [DATE] at 10:20 a.m., the resident's hard chart was reviewed. The hard chart had a green dot on the outside of the chart. The chart contained a document titled Physician Order which had CPR marked on the form. The chart did not contain documentation of the resident or representative being offered an advanced directive. On [DATE] at 3:09 p.m., the DON stated…

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, record review, and interview the facility failed to have evidence a thorough investigation was conducted related to an allegation of abuse and prevent further potential abuse/mistreatment while the investigation was in progress for one (#111) of two sampled residents for abuse. The Residents Census and Conditions of Residents form documented 27 residents resided in the facility. Findings: Res #111 admitted to the facility and had diagnoses which included myocardial infarction, depressive disorder, and schizophrenia. A quarterly assessment, dated 05/15/23, documented the resident was intact with cognition and required limited to extensive assistance with ADLs. On 08/15/23 at 4:18 p.m., the resident was observed sitting in their room on the bed. Res #111 stated a male aide got mad at them last night because they used the call light to call for ice water. Res #111 stated most of the staff are good. Res #111 stated they threaten them all the time with sending them to room with another resident which the resident did not wish to be around. During the interview a NA…

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 and interview, the facility failed to ensure an RN worked eight consecutive hours seven days a week. The Resident Census and Conditions of Residents report, dated 08/15/23, documented 27 residents resided in the facility. Findings: On 08/13/23 at 4:04 p.m. an observation was made of all staff working in the facility this date. There was no RN identified working in the facility this day. On 08/13/23 at 4:06 p.m., the charge nurse/LPN #1 was interviewed regarding the RN coverage for the day. The LPN stated she had not seen an RN today since she arrived about 7:00 a.m. this morning. The LPN stated there was an RN scheduled for day shift, but she had not seen an RN and did not know if they would have one today. The LPN stated the facility did not always have RN coverage, usually once or twice a week, especially on the weekend. On 08/13/23 at 4:35 p.m., the DON entered the facility. The DON stated she did not know there was no RN coverage today. The DON stated she received a text message from a staff member advising the state surveyor was in the facility, but not…

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 record review and interview, the facility failed to ensure labs were collected for one (#111) of five sampled resident's reviewed for lab service. The Residents Census and Conditions of Residents form, documented 27 residents resided in the facility. Findings: Res #111 admitted to the facility and had diagnoses which included myocardial infarction, depressive disorder, and schizophrenia. A quarterly assessment, dated 05/15/23, documented the resident was intact with cognition and required limited to extensive assistance with ADLs. A physician order, dated 05/31/23, documented to decrease Coumadin (an anticoagulant medication) to 6 mg daily and redraw PT/INR in one week. A physician order, dated 06/01/23, documented Coumadin 6 mg one time a day related to myocardial infarction. A nurse note dated 06/01/23 at 7:15 a.m., documented the resident was sent to the ER. A nurse note, dated 06/01/23 at 5:00 p.m., documented the resident would be monitored overnight related to PT/INR and Coumadin changes. A nurse note, dated 06/02/23 at 2:00 p.m., documented the resident returned to…

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 record review and staff interview, it was determined the facility failed to train/orient new employees on abuse, neglect, and exploitation. The Resident Census and Conditions of Residents form documented 27 residents resided in the facility. An Abuse Prevention Program policy read in part, .Protect our residents abuse by anyone including, but not necessary limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .Required staff training/orientation programs that includes such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior .Abuse, neglect, and exploitation toward residents. On 09/12/23 at 9:10 a.m., the SS/BOM was asked about staff training related to abuse, neglect, and exploitation on hire. On 09/12 23 at 12:50 p.m. an observation was made of [NAME] #1's employee file and the file only had an application for employment in it. a. LPN #2; hire date…

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 record review, observation, and interview, the facility failed to ensure comprehensive resident assessments were completed within 14 days of admission and annually for four (#128, 17, 23, and #127) of 26 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 33 residents who resided in the facility. Findings: 1. Res #128 was admitted on [DATE] with diagnoses which included hypertension and unspecified osteoarthritis. On 05/11/22 at 11:16 p.m., Res #128 was observed sitting in a wheelchair in their room. A review of Res #128's clinical record was conducted on 05/17/22 and did not document a comprehensive admission assessment had been completed. 2. Resident #17 had diagnoses which included disc degeneration, thrombosis of unspecified deep veins of lower extremity, and diverticulitis of intestine. A review of Res #17's clinical record was conducted on 5/17/22 and documented the most recent annual assessment had been conducted on 02/25/21. 3. Res #23 had…

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 record review and interview, the facility failed to complete a resident assessment at least quarterly for six (#78, 6, 1, 14, 2, and #5) of 26 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 33 residents resided in the facility. Findings: 1. Res #6's clinical records were reviewed and the most recent resident assessment was dated 12/16/21. 2. Res #1's clinical records were reviewed and the most recent resident assessment was dated 12/20/21. 3. Res #14's clinical records were reviewed and the most recent resident assessment was dated 12/06/21. 4. Res #2's clinical records were reviewed and the most recent resident assessment was dated 12/22/21. 5. Res #5's clinical records were reviewed and the most recent resident assessment was dated 12/29/21. On 05/12/22 at 4:59 p.m., the DON stated the assessments had not been completed. 6. An annual MDS assessment, dated 08/07/21, for Res #78 was completed. The quarterly assessment, dated 11/07/21, documented the resident was moderately cognitively impaired and was independent…

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 record review, observation, and interview, the facility failed to ensure resident assessments were transmitted to CMS within seven days of completion for three (#21, 19, and #24) of 26 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 33 residents resided in the facility. Findings: 1. Res #21 had diagnoses which included acute embolism of unspecified deep veins of unspecified lower extremity, diabetes, and gastro-esophageal reflux disease. On 05/17/22, a review of Res #21 clinical record showed a quarterly resident assessment had been completed on 04/01/22. 2. Res #19 had diagnoses which included cerebral infarction, paranoid schizophrenia, and epilepsy. On 05/17/22, a review of Res #19's clinical records showed a quarterly resident assessment had been completed on 04/07/22. 3. Resident #24 had diagnoses which included amnesitic disorder, suicidal ideation, and impulse disorder. On 05/17/22, a review of Res #24's clinical records showed a quarterly resident assessment had been completed on 04/07/22. A CMS transmittal…

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 record review, observation, and interview, the facility failed to ensure the consultant pharmacist requested a GDR for one (#18) of five residents sampled for unnecessary medications and failed to ensure the MRR policy documented time frames for each step in the process. The Resident Census and Conditions of Residents form documented 33 residents resided in the facility. Findings: A facility policy titled Medication Regimen Reviews, dated April 2007, read in part: .The primary purpose of this review is to help the facility maintain each resident's highest practible level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible . Res #1 had diagnoses which included schizoaffective disorder, anxiety disorder, and extrapyramidal and movement disorder. A physician order, dated 07/16/19, documented the facility was to administer risperidone (an antipsychotic medication) 3 mg tablet twice daily for a diagnosis of schizoaffective disorder. A physician order, dated 09/04/19,…

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 record review and interview, the facility failed to obtain lab services as ordered by the physician for two (#126 and #127) of five residents reviewed for unnecessary medication. The Resident Census and Conditions of Residents form documented 33 residents resided in the facility. Findings: 1. Res #126 had diagnoses which included dementia, adult failure to thrive, and chronic embolism of deep vein of lower extremity. A physician order, dated 03/25/22, documented the facility was to obtain a CBC, CMP, lipid panel, and liver lab test every six months in March and September. A physician order, dated 03/25/22, documented the facility was to obtain a HgBA1C lab test every three months in March, June, September, and December. A physician order, dated 03/25/22, documented the facility was to obtain a TSH lab test every 12 months. Res #126's admission assessment, dated 04/06/22, documented Res #126 was moderately impaired in cognition and was independent with most activities of daily living. On 05/16/22 at 3:20 p.m., Res #126's clinical record was reviewed and found to contain no…

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 record review, observation, and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The Census and Conditions of Residents form documented 33 residents lived in the facility. Findings: On 05/12/22 at 3:17 p.m., two ceiling tiles in the kitchen were observed drooping down and were discolored. One was over the refrigerator and one was over the vent hood. The fan levers were observed to be covered with dust and cobwebs some were hanging down from the fan levers and ceiling. On 05/12/22 at approximately 3:20 p.m., a cleaning schedule for September 2021 was observed hanging in the kitchen. There was no one on the list assigned to clean the ceiling fan levers. On 05/12/22 at 3:30 p.m., cook #1 stated it was maintenance who cleaned the fan levers, but the facility does not have a maintenance man at this time. On 05/12/22 at 3:24 p.m., the dietary aide was observed to return to the kitchen from the dining room and did not wash her hands before touching the drink pitchers made up for the residents. On 05/12/22 at 3:32 p.m., cook #1…

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 and interview, the facility failed to ensure an open shelved insulin cart with different residents' medications did not enter resident rooms. The Resident Census and Conditions of Residents report documented 33 residents resided in the facility. Findings: On 05/12/22 at 4:38 p.m., LPN #1 was observed to roll a three shelf open cart into Res #21's room. The cart was positioned in front of the resident who was sitting in his W/C. The cart contained different residents' insulin, insulin syringes, insulin pens, and glucometer on the top shelf, along with gloves, disinfected wipes, and a sharps container. The resident received a FSBS and two types of insulin. On 05/12/22 at 4:46 p.m., LPN #1 rolled the same cart into Res #78's room. The resident received a FSBS and two types of insulin. The resident's roommate also received insulin. On 05/12/22 at 4:52 p.m., LPN #1 was asked about taking the cart with different residents' insulin and supplies into each room. She stated she has always taken the cart into the rooms. She stated they did not have an enclosed locked cart…

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 record review, observation, and interviews, the facility failed to maintain an effective pest control program so that the facility was free of bed bugs and roaches. The Resident Census and Conditions of Residents form documented 33 residents resided in the facility. Findings: On 05/11/22 at 10:10 a.m., Res #23's room was observed. The mattress was turned up and leaning against the wall. Two bed bugs were observed on the bottom of the mattress cover and spots of blood were observed on the wall next to the bed. At that time, the administrator stated the facility had been treated with Diatomaceous Earth that morning. The administrator stated the exterminator would be called. On 05/11/22 at 10:19 a.m., CNA #2 stated the facility has had bed bugs for several months. CNA #1 also stated they had observed bed bugs in multiple residents' beds and on the room divider curtains and the window curtains. They said the administrator was aware. On 05/11/22 at 12:26 p.m., Res #17's bed was observed with blood on the bedding. A dead bed bug was observed in the bed. A live bed bug was…

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 record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan based on the resident assessment for one (#13) of ten residents whose records were reviewed for care plans. The Resident Census and Conditions of Residents form documented 33 residents resided in the facility. Findings: Res #13 had diagnoses which included bipolar disorder, epileptic seizures, and dementia. An admission assessment, dated 03/01/22, documented Res #13 had moderate difficulty hearing and vision impaired, had verbal behaviors directed toward others, and was independent with most activities of daily living. On 05/11/22 at 2:24 p.m., Res #13 was observed sitting on the front porch and had a cochlear implant and hearing aides. Res #13 stated the wire on the cochlear implant was cracked and their left hearing aide was broke. Res #13 stated one of the lenses of their glasses kept falling out and a tooth was bothering them. On 05/16/22, a review of Res #13's clinical records did not contain a comprehensive care plan. On 05/16/22 at 2:55 p.m., the DON…

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 record review, observation, and interview, the facility failed to notify the the physician, obtain orders for treatment, and assess a pressure ulcer in a timely manner for one (#78) of two residents sampled for pressure ulcers. The Resident Census and Conditions of Residents report documented no residents had pressure ulcers. Findings: Resident #78's quarterly assessment, dated 11/07/21, documented the resident was moderately cognitively impaired, was independent to requiring limited assistance with ADLs, and had impairment on one side of his upper and lower extremities. The assessment documented the resident did not have pressure ulcers. On 05/11/22 at 11:00 a.m., the resident stated he had a sore on his ankle. CNA #2 was called in to help position the resident to visualize the ankle. The CNA stated she had noticed a discolored area on his ankle but it was not open. The resident's lateral (exterior) left ankle was observed to have an approxiatmate 1 cm open area with full thickness skin loss and pink drainage on the linens. The CNA stated she would tell the nurse. The CNA…

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 record review, observation, and interview, the facility failed to assist a resident to obtain dental services for one (#13) of one resident reviewed for dental services. The DON identified two residents in the facility who had obvious dental caries. Findings: Res #13 had diagnoses which included epileptic seizures, bipolar disorder, Parkinson's disease, and schizoaffective disorder. A resident admission assessment for Res #13, dated 03/01/22, documented Res #13 was intact in cognition and had obvious or likely cavities or broken natural teeth. A nurse note, dated 03/28/22 at 2:20 p.m., read in part: .Resident wants tooth filled. Nurse explained insurance only provides payment for tooth to be pulled. Resident yelled at nurse that [pronoun deleted] isn't having a tooth pulled. On 05/11/22 at 2:22 p.m., Res #13 was observed sitting on the front porch of the facility. Res #13 was observed to have several upper and lower teeth. Res #13 stated they needed to go to the dentist for treatment of a sore tooth for some time and no one at the facility would help with arranging an…

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.