RAINBOW TERRACE CARE CENTER
For profit - Corporation
60 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
1/100
#257 of 282 in OK
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Rainbow Terrace Care Center in Weleetka, Oklahoma, has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #257 out of 282 facilities in Oklahoma places it in the bottom half of nursing homes statewide, and #3 out of 3 in Okfuskee County means there is only one other local option that is better. The facility is worsening, with issues increasing from 1 in 2024 to 4 in 2025, highlighting a troubling trend. While staffing is rated average at 3 out of 5 stars, the turnover rate is impressively low at 0%, suggesting staff stability, but the facility has accumulated $60,140 in fines, which is higher than 93% of other Oklahoma facilities and indicates repeated compliance problems. There are critical incidents that raise serious concerns, such as failing to ensure background screenings for employees, which puts residents at risk for abuse, and a situation where CPR was initiated on a resident without proper emergency protocols being followed, leading to a delay in contacting EMS. Additionally, the facility had a serious incident related to skin care management, where a resident did not receive appropriate interventions to prevent skin injury, indicating potential neglect. Overall, families should be aware of both the staffing stability and the alarming compliance issues when considering this facility for their loved ones.
- Trust Score
- F
- In Oklahoma
- #257/282
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ⚠ Watch
- $60,140 in fines. Higher than 99% of Oklahoma facilities. Major compliance failures.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Oklahoma. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 49 deficiencies on record. Higher than average. Multiple issues found across inspections.
1/100
Bottom 9%
Review needed
1 → 4 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 4 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Oklahoma average (2.6)
Significant quality concerns identified by CMS
Federal Fines: $60,140
Above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 49 deficiencies on record
2 life-threatening 1 actual harm
Jan 2025
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a referral was made to the LOCEU for one (#18) of three sampled residents reviewed for PASSARs.
The DON identified five residents wi...
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Based on record review and interview, the facility failed to ensure a referral was made to the LOCEU for one (#18) of three sampled residents reviewed for PASSARs.
The DON identified five residents with a PASSAR level ll after a referral to the LOCEU.
Findings:
Resident #18 had diagnoses which included delusional disorderes and major depressive disorders.
A PASSAR level l, dated 05/25/21, documented the resident had a diagnosis of a serious mental illness. The form documented a referral was to be made to the LOCEU for consultation.
On 01/07/25 at 12:08 p.m., the DON reviewed the resident's PASSAR level l and stated per the documentation a PASSAR level ll referral should have been made to the LOCEU. The DON stated per documentation a referral had not been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to have an antibiotic stewardship program with a system to monitor antibiotic use for the residents.
The DON identified five residents who we...
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Based on record review and interview, the facility failed to have an antibiotic stewardship program with a system to monitor antibiotic use for the residents.
The DON identified five residents who were currently receiving an antibiotic medication.
Findings:
A policy titled Antibiotic Stewardship, read in part The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents.
On 01/07/25 at 2:53 p.m., the DON stated there had been no documented infection control monitoring completed since November 2023. The DON stated they were not aware they were responsible for infection control or antibiotic stewardship monitoring. The DON stated there was no tracking/ monitoring for the use of antibiotics in the facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week.
The administrator identified 29 residents resided in the facility.
Fi...
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Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week.
The administrator identified 29 residents resided in the facility.
Findings:
The work schedule for July 2024 through August 2024 documented no RN coverage for 7/12, 8/6, 8/16, 8/17, 8/18, 8/23, 8/24, 8/25, 8/29, and 8/30.
On 01/08/25 at 12:46 p.m., the DON stated in July and August they were short staffed on RNs and did not have RN coverage every day.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to follow infection control practices during a mediation pass and failed to ensure EBP was followed during wound care for one (#...
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Based on observation, record review, and interview, the facility failed to follow infection control practices during a mediation pass and failed to ensure EBP was followed during wound care for one (#11) of one sampled resident observed during wound care.
The DON identified 29 residents who resided in the facility and four residents who were on enhanced barrier precautions.
Findings:
A document titled Medical Glove Policy and Procedure, read in parts The purpose of this policy is to establish guidelines for the proper use of medical gloves in order to prevent the transmission of infections and ensure the safety of residents and healthcare workers .Change gloves between tasks and procedures on the same patient to prevent cross-contamination.
A document titled Policy and Procedure: Enhanced Barrier Precautions, read in parts Enhanced Barrier Precautions (EBPs) is a Centers for Disease Control and Prevention (CDC) recommendation to provide guidance for use of personal protective equipment (PPE) in facilities for preventing the spread of multi-drug resistant organisms (MDROs) .The facility may choose to implement enhanced barrier precautions to include any resident with an indwelling medical device or wound .appropriate signage for type of precaution will be posted on room door .Isolation cart containing appropriate PPE and hand sanitizer will be readily accessible for use .The IP/Designee will provide staff, residents and/or resident representatives with education regarding the purpose of enhanced barrier precautions.
1. On 01/07/25 at 7:10 a.m., LPN #1 was observed preparing a medication administration for a resident. The LPN donned a pair of gloves, opened cart drawers, obtained medication from different medication bottles and packages, and turned pages on the paper MAR. Using the same gloved hands the LPN prepared to crush the medications by placing the tablet/capsule each time in their gloved hand, then placed the medication in a plastic envelop to crush.
On 01/07/25 at 7:23 a.m., the LPN #1 stated they should not have placed the tablet/capsule in their unclean gloved hand. The LPN stated they should have changed their gloves and washed their hands between tasks and touching unclean surfaces.
On 01/08/25 at 1:13 p.m., the DON stated LPN #1 should have washed their hands and changed gloves between tasks.
2. On 1/08/25 at 8:00 a.m., LPN #1 washed their hands and donned gloves, but did not wear a gown. Resident #11's covers were removed and they were rolled onto their right side revealing a dime sized open area on the left buttocks. LPN #1 cleansed the open area with wound cleanser and applied lanolin.
On 1/08/25 at 8:10 a.m., LPN #1 stated they had never worn a gown to perform wound care only gloves. They stated they were not aware of an enhanced barrier precautions policy.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to provide pressure ulcer treatment as directed for one (#2) of three residents reviewed for pressure ulcers/wounds.
The DON reported the facil...
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Based on record review and interview the facility failed to provide pressure ulcer treatment as directed for one (#2) of three residents reviewed for pressure ulcers/wounds.
The DON reported the facility had one resident in the facility with a wound.
Findings:
A facility policy, revised January 2002, titled Wound Care, read in part .The purpose of this procedure is to provide guidelines for the care of wound to promote healing. 1. Verify there is a physician's order for this procedure .If the resident refuses the care, inform your supervisor .The following information should be recorded in the resident's medical record: .If the resident refused the treatment and the reason(s) why .Report other information in accordance with facility policy and professional standards of practice.
Res #2 had diagnoses which included edema, paraplegia,and dementia with behaviors,
A quarterly assessment documented the resident was at risk for pressure ulcers and had MASD.
A physician order, dated 10/09/23, documented Santyl external ointment to apply to affected area every 72 hours for open areas related to paraplegia.
The TAR for February and March 2024 were reviewed and 10 treatments were not completed according to the documentation. The resident's clinical records, including the TARs) were reviewed and did not document a reason the treatments had not been carried out.
On 03/27/24 at 2:40 p.m., RN #1 stated the resident often refused wound care. RN #1 stated according to the TAR for February and March the wound care was not completed as ordered and confirmed there was no documentation of the resident refusing the treatment.
On 03/27/24 at 3:37 p.m., the DON stated the wound care for the resident had not been completed as ordered by the physician. The DON stated there was no documentation why the wound care was not completed in the resident's clinical records.
Sept 2023
15 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Abuse Prevention Policies
(Tag F0607)
Someone could have died · This affected multiple residents
On 08/17/23 at 5:45 p.m., an Immediate Jeopardy situation was determined to be in existence related to the facility failing to ensure background screenings were completed for four of 29 employees hire...
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On 08/17/23 at 5:45 p.m., an Immediate Jeopardy situation was determined to be in existence related to the facility failing to ensure background screenings were completed for four of 29 employees hired between 2022 and 2023. The facility failed to ensure residents were not at risk for abuse related to staff background screening and finger printing not being completed.
On 08/17/23 at 5:50 p.m., the charge nurse on duty was informed of an Immediate Jeopardy situation and the IJ template was emailed to the DON at that time. The administrator, assistant administrator, and DON were not in the facility at that time.
On 08/21/23 at 4:38 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health by the assistant administrator.
The facility plan of removal, read in entirety, Immediate Jeopardy Plan of Removal 8/18/2023
On 8/17/2023 at 5:50 PM, an Immediate Jeopardy situation was announced to the ADON, [name withheld]. The Immediate Jeopardy was due to the facility not having up to date background checks on 4 out of 29 employees hired between 2022 and 2023. On March 20, 2023, the Administrator that was in charge of background checks suffered a stroke, and he was the one that had access to OkScreen. On 8/17/2023, an email was sent to OkScreen to regain access to the site. Access was granted on 8/18/2023 and at 0800 [8:00 a.m.], the payment was submitted. According to the OkScreen site, full access to the background check site will not be fully functioning until one business day after the payment is rendered.
Copies of the background checks for [NA #1 name withheld] and [NA #3 name withheld] were obtained and they will remain in the employee charts until the facility gains access to the OkScreen site. At this time, the employees will be verified through the site. The remaining two employees that do not have background checks do not work directly with residents. They have been checked by ODCR and do not hold any criminal records. As soon as access is granted to the site, these individuals will be set up for a fingerprint screening. Until they have their fingerprints, these individuals that work in the kitchen will not have any interaction with residents that reside in the facility. Both kitchen workers have been contacted, and informed that they are not to have any contact with the residents. The cook in the kitchen has been notified that they are to watch for contact with residents, and the charge nurse will be notified if contact is made. Both the cooks and charge nurses have been notified to watch for any contact, and if contact is made, those without a background check will be asked to leave the facility. The charge nurses and kitchen cooks have been notified by telephone of these changes. Notifications have been finished by 11:45 AM on 8/18/2023.
Since the facility will soon have access to the OkScreen site, a list of all employees will be run and compared to the employees that are listed on the facility profile. Any employee that is missing a background check will be verified, and if no previous check has been completed, the employee will be scheduled for fingerprinting. To continue to remain in compliance, once compliance is reached, a new system will be created to ensure that background checks are completed in a timely manner. Any future employees will have to be submitted for a background check as soon as it is determined that they are of hiring potential. The Office Manager will assist the RN Consult with monthly auditing of employees to ensure that no background checks are missed.
In-service has been given to the people that are in charge of hiring to ensure that they initiate a background check before someone is placed on the schedule. The office assistant has been in-serviced on overlooking employee files monthly. In-services have been completed as of 11:45AM on 8/18/2023. Access was regained to OkScreen site, and background checks were completed for: [Cook #3, DA #3, [NAME] #1, DA #2, NA #1, NA #3, NA #4, NA #5, DA #1, and Maintenance Worker #1, names withheld].
According to a search of the SOM, there is no Federal Regulation that states how long an employee leaving on good terms must be terminated before getting rehired. That was thoroughly checked and the facilities policy was reviewed to ensure that employees were rehire able [sic]. Per the documentation that has already been sent, in-service was provided to those in charge of hiring, in-service was provided to the office assistant that reviews charts and in-service was held with the employees that were awaiting checks, the charge nurses and the supervisors that were in the kitchen, as they would be watching to ensure those needing background checks were not around the residents. It is still believed that the facility completed all steps necessary to ensure safety, as you can't schedule fingerprints until ALL background checks have been run.
The IJ was lifted, effective 08/29/23, when all components of the plan of removal had been completed and the employees who did not have background checks and fingerprinting were completed. The deficiency remained at a widespread level with potential for more than minimal harm.
Based on interview and record review, the facility failed to ensure background screenings were completed prior to employment for 13 of 33 employees reviewed for background screening.
The Resident Census and Conditions of Residents form documented 27 residents resided at the facility.
Findings:
A Background Screening Investigation policy, revised November 2015, read in part, .1. The Personnel/Human Resources Director, or other designee, will conduct background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by stated law) on all potential employees and contract personnel who meet the criteria for direct access employee, as stated above. Such investigation will be initiated within two days of an offer of employment or contract agreement .
On 08/17/23 at 2:01 p.m., the SS director/BOM stated they had done all the hiring in the last two years and no one had been screened. The SS director stated the new hires could not be ran through OK screen because they could not get into the system. SS director stated the administrator could not remember the password and they would have to get it reset.
On 08/17/2023 at 3:18 p.m., a staff list was provided with the date of hire and the list documented whether the staff had or did not have a background screening. The list documented 11 staff did not have background checks.
On 08/22/23 at 10:06 a.m., the program manager for the Oklahoma National Background Check Program was contacted and a report was obtained which listed six of 17 staff who the facility recently registered with OK screen.
On 09/12/23 at 11:06 a.m., the program manager for the Oklahoma National Background Check Program was contacted and they sent a report which documented 19 of 19 total staff who had background checks and finger printing completed. The report documented the facility had two staff eligible on 08/20/23, two staff eligible on 08/21/23, five staff eligible on 08/27/23, and three staff eligible on 08/29/23.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Res #115 was admitted to the facility on [DATE] with diagnoses of intracranial hemorrhage, chronic pancreatitis, pain in unsp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Res #115 was admitted to the facility on [DATE] with diagnoses of intracranial hemorrhage, chronic pancreatitis, pain in unspecified limb, diabetes mellitus, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, and vitamin D deficiency.
The care plan, initiation date of 09/12/17 and last revised on 09/12/17, documented the resident had potential impairment to skin integrity related to fragile skin and poor mobility. The goal was the resident would maintain or develop clean and intact skin by the review date with a target date of 09/20/21. The interventions included the following:
a. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short.
b. Educate resident/family/caregivers of causative factors and measures to prevent skin injury.
c. Encourage good nutrition and hydration in order to promote healthier skin.
d. Follow facility protocols for treatment of injury.
e. Identify/document potential causative factors and eliminate/resolve where possible.
A quarterly assessment, dated 06/04/23, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident had no pressure ulcers but was at risk for pressure ulcers.
An annual assessment, dated 06/17/23, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident had no pressure ulcers but was at risk for pressure ulcers.
On 08/15/23 at 11:58 a.m., CNA #1 was observed rolling the resident on their right side and an observation was made of a scar with an open nickel size pressure ulcer on it on their left hip. The CNA stated she would let the nurse know about the wound.
A weekly skin assessment, dated 08/15/23, documented the resident had a P for problem on the left hip.
A pressure ulcer report, dated 08/15/23, documented the resident had a stage II pressure ulcer measuring 3.0 x 2.5 cm on their left hip and an order was obtained to treat with barrier cream.
On 08/17/23 at 10:47 a.m., an observation was made of the wound while CNA #1 repositioned the resident. The pressure ulcer was observed open and had a scant amount serosanguinous fluid on it. Res #115 reported the wound had been on his left hip for more than two months.
On 08/17/23 at 11:50 a.m., an interview was conducted with LPN #1 and they stated CNA #1 had reported the wound to them on 08/15/23 and an order was obtained to treat the wound with barrier cream. The LPN stated the physician did examine the resident on 08/17/23 and stated to continue the previous order of barrier cream.
Based on observation, record review, and interview, the facility failed to:
a. complete pressure ulcer assessments which included measurements and description for one (#128);
b. notify the physician of a wound area and unstageable pressure ulcer timely for one (#128); and
c. have a care plan in place and/or updated to prevent pressure ulcers for residents at risk for ulcers for two (#128 and #115) of two residents reviewed for pressure ulcers. Res #128's medical records documented a scabbed area to the resident's coccyx that continued through June and July 2023 without assessment or physician notification. On 07/28/23 the unstageable ulcer was assessed and measured at 3.0 x 5.0 x 1.0 cm. The physician was notified on 07/31/23 and an order for treatment was obtained.
The Resident Census and Conditions of Residents report, dated 08/15/23, documented no with resident pressure ulcers.
Findings:
A facility policy and procedure titled, Pressure Ulcer Treatment, documented a stage I pressure ulcer was a persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved. The policy documented interventions/care strategies were to evaluate until redness was no longer persistent; notify physician, family and appropriate facility personnel; and initiate a skin grid and care plan.
A Pressure Ulcer Risk Assessment Policy, revised 03/2005, read in part, .10. Routinely assess and document condition of the resident's skin per facility wound and skin program for any signs and symptoms of skin irritation or skin breakdown. Immediately report any signs of a developing pressure ulcer to supervisor .assess for the presence of developing of pressure ulcers on a weekly basis or more frequently if indicated .
1. Resident #128 was admitted to the facility on [DATE] with diagnoses which included non-traumatic intracerebral hemorrhage in the brain stem and encephalopathy.
An admission assessment, dated 05/11/23, documented the resident was not impaired for daily decision making, was total dependent for ADLs, and had a catheter. The assessment documented the resident did not have a pressure ulcer or skin issues. The assessment documented the resident was at risk for pressure ulcers. The CAA triggered for pressure ulcers to be care planned.
A weekly skin assessment log, for the weeks 05/01/23 through 07/31/23, documented a P each week on Monday to the coccyx area. The log defined a documented P as representing an area with a newly noted problem. The log documented more detail would be provided on a separate, detailed sheet. The log documented clear skin would be indicated with the letter C.
A Skin Note, dated 05/01/23, documented the resident had an area to the coccyx, with rolled up skin, and no redness or open area noted.
A Skin Note, dated 05/08/23, documented the resident continued to have an unopened area to the coccyx. The note documented the resident had an order for barrier cream through hospice services. The physician orders and TAR did not document an order for barrier cream. There was no assessment or notification of the physician documented in the record.
A Skin Note, dated 05/15/23, documented the resident continued to have an area to the coccyx with no open areas noted. An assessment was not documented or physician notified.
A Skin Note, dated 05/29/23, documented the resident had a scratch to the coccyx area. The note documented no erosion seen or further breakdown noted.
A Skin Note, dated 06/05/23, documented a scabbed area to the coccyx with barrier cream continued to be used. An assessment and physician notification was not documented.
A Skin Note, dated 06/12/23, documented a scabbed area on coccyx with no open areas noted. There was no documentation of a wound assessment or notification to the physician regarding the unstageable wound.
A Skin Note, dated 06/19/23, documented a calloused area to the coccyx with no open areas and applied barrier cream on coccyx to protect. No assessment was documented or physician notification.
A Skin Note, dated 07/03/23, documented an area to the coccyx remained closed with no redness noted. The note documented CNA to use barrier cream for protection. No assessment or notification was recorded.
A Skin Note, dated 07/10/23, documented the resident continued to have a calloused, unopened area to the coccyx. No assessment or notification to the physician was documented.
A care plan, initiation date of 07/19/23, documented the resident had little or no activity involvement related to physical limitations and physical mobility related to stroke. The care plan documented the resident had an ADL self-care performance deficit related to a brain stem injury. The care plan documented the resident had potential/actual impairment to skin integrity of the coccyx related to fragile skin. The care plan documented the following interventions:
a. Educate resident/family/caregivers of causative factors and measures to prevent skin injury.
b. Encourage good nutrition and hydration in order to promote healthier skin.
c. Follow facility protocols for treatment of injury.
d. Monitor/document location, size and treatment of skin injury.
e. Report abnormalities, failure to heal, sign and symptom of infection, maceration, etc. to physician. The MDS triggered for care planning for pressure ulcers on 05/11/23. The care plan was not created until 07/19/23.
A Skin Note, dated 07/25/23, documented the resident had a rash under the left arm. The note documented the physician was notified for orders. The note documented the area on the coccyx was red with a callous and not open. There was no wound assessment or mention of the coccyx wound if reported to the physician.
A physician note, dated 07/26/23, documented the chief complaint was the resident was being seen for gurgling. The note stated a chest x-ray was ordered. The note documented in the skin section of the document to see the detailed report in the patient record. There was no detailed skin report at that time.
A Skin Check assessment, dated 07/28/23, documented a stage II/unstageable 3.0 cm x 5.0 cm x 1.0 cm pressure ulcer to the coccyx. No notification to the physician and no order was obtained.
A Skin Note, dated 07/28/23, documented scratches noted to coccyx area and cream was applied. This documentation did not coincide with the previous assessment.
A Skin Check assessment, dated 07/31/23, documented a stage II to coccyx and dressing orders received.
A Skin Note, dated 07/31/23, documented area to coccyx noted to be open, approximately 3.0 cm x 5.0 cm x 1.0 cm. Physician notified for wound orders and dressing applied to coccyx.
A physician order, dated 07/31/23, documented to apply a Santyl and Alginate pad with an island dressing. The order documented to change the dressing every 72 hours and as needed for soiling or dislodgement. The TAR or resident record did not document a dressing change was performed at any time before the resident left the faciity on [DATE].
A nurse note, dated 08/02/23, documented the resident had hematuria (blood in urine) and an elevated temperature, 101.1-degree Fahrenheit. The note documented a new ulcer to the coccyx area 3.0 cm x 5.0 cm x 1.0 cm that was previously a calloused area. The note documented the resident was sent to the hospital for evaluation.
A significant change assessment, dated 08/04/23, documented the resident was modified independent for daily decision making, was total dependent for ADLs, and had a catheter. The assessment documented the resident had one stage II pressure ulcer.
On 08/14/23 at 11:09 a.m., a family member was interviewed regarding the resident. The family stated the hospital advised surgery was needed for the wound.
On 08/21/23 at 11:41 a.m. the DON reviewed the resident's records. The DON stated the resident had an unstageable pressure ulcer on the 07/28/23. The DON stated the physician was not notified on the 07/28/23 of the unstageable pressure ulcer.
On 08/21/23 at 12:25 p.m., LPN #1 was observed sitting at the nurse station completing August 2023 TARs for the resident. The LPN did not provide the TAR for August 2023.
On 09/12/23 at 1:10 p.m., the DON provided the resident's MARs and TARs for July 2023 and August 2023. The documents did not document the physician order received for Santyl and Alginate 07/31/23. The DON stated the order must not have printed to the TAR, but was documented in a Skin Note as completed. The DON stated there was not an order for barrier cream because the facility had standing orders for the use of barrier cream. The DON provided a document titled Rainbow Terrace Care Center Standing Orders. The document did not have a physician signature. The DON was unsure about a physician signed copy of the standing orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**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 (...
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**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 they did not know what the residents wishes were for an advanced directive and DHS did not sign an advance directive for the resident. The DON stated the advanced directive form offering the resident to decline an advanced directive was not in the admitting paperwork. The DON stated they did not use the advance directive form for new admissions.
On [DATE] at 10:28 a.m., Res #101 was observed in the lobby of the facility ambulating without assistance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
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/mis...
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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 #1 entered the room. Res #111 stated NA #1 was the one that threatened the resident for using the call light. The resident was asked if he was afraid at this time. Res #111 stated they were not afraid and nothing had ever happed by the other resident. Res #111 stated that was the first time NA #1 had ever asked the resident if they needed anything. Res #111 stated they had not reported the allegation it to anyone till now.
On 08/15/23 at 4:43 p.m., the allegation of abuse related to NA #1 and Res #111 was reported to the DON. The DON went and spoke with the resident at that time.
A state incident report form 283, with a fax date of 08/15/23 and an incident date of 08/14/23, was reviewed which documented the resident reported an allegation of [name withheld] CNA saying that the call lights were for emergencies and if the resident did not quit acting out the resident would be moved in with another resident.
A nurse aide registry incident form 718, with an incorrect date of 06/07/23, documented the employee was not suspended.
The investigation documented the resident's room mate, two other residents on the hall, one NA, one CMA, and one nurse were interviewed. The investigation did not contain a statement by the alleged perpetrator NA #1.
On 08/21/23 at approximately 3:40 p.m., the DON stated they did not have the NA in question to clock out and leave the building after an allegation of abuse had been made. The DON stated they did interview NA #1 but must not have written it down.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
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, docume...
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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 advised there was no RN coverage for the day.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
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 Resi...
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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 the facility via wheel chair. The nurse note documented the resident had no medication changes and to continue orders as previously written.
A PT/INR was not found to be obtained for June after the resident returned from the hospital. A PT/INR was not obtained for the resident in July.
On 08/17/23 at 3:27 p.m., the DON stated the resident should have a PT/INR at least once a month.
On 08/18/23 at 10:48 a.m., the DON stated if the labs were not in the chart, they did not have them.
On 08/18/23 at 11:40 a.m., the DON stated the physician had been in the facility since the resident had returned from the hospital and wrote no new orders.
On 08/18/23 at 1:53 p.m., the physician returned a phone call. The physician stated the resident had been in and out of the hospital and returned on the same dose of Coumadin, so for the PT/INR in June the hospital would have done one. The physician stated the facility should have obtained a PT/INR for the resident in July.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected 1 resident
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 fo...
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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 07/16/23,
b. [NAME] #1; hire date 08/08/23,
c. [NAME] #2; hire date 08/26/21.
d. Dietary Aide #1; hire date 04/28/23,
e. Dietary Aide #2; hire 09/17/20.
On 09/12/23 at 12:55 p.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. They also state if it is not in the employee file then it was not done and education and orientation was a complete oversight.
On 09/12/23 at 3:02 p.m., an interview was conducted with the DON and they stated in-services were done twice a month on abuse, neglect, exploitation, resident's having aggressive behavior but the new employees had to wait for in-service day to be train/oriented. They also stated they would start training/orientation on abuse, neglect, and exploitation upon hire.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide privacy for seven (#101, 103, 110, 111, 115, 125, and #127) of seven resident reviewed for privacy.
The Resident Census and Condition...
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Based on observation and interview, the facility failed to provide privacy for seven (#101, 103, 110, 111, 115, 125, and #127) of seven resident reviewed for privacy.
The Resident Census and Condition of Residents, documented a census of 27 residents.
Findings:
1. Res #101 was admitted to the facility and had diagnoses which included major depressive disorder and dementia.
An admission assessment, dated 08/09/23, documented the resident was moderately impaired with cognition and was independent with most ADLs.
On 08/16/23 at 9:05 a.m., there were no curtains or covering of any kind on the window in the resident's room. Res #101 stated they would like to have a window covering but could not afford one. The resident's room was on the west hall facing the parking lot and street.
On 08/16/23 at 9:50 a.m., maintenance staff #1 stated they were waiting for new curtain rods to come in and then would put the curtains up.
On 08/18/23 at 8:47 a.m. the DON stated we cannot provide privacy at this time for the residents. We are in the process of buying and installing new curtains rods and we just bought a new washer and dryer to wash the curtains. Once we have started washing the curtains and as soon as we get the curtain rods up the residents will have their privacy back.
2. Res # 103 admitted to the facility and had diagnoses which included major depressive disorder, HTN and Dementia.
An admission assessment, dated 11/09/22, documented the resident was moderately impaired with cognition and required extensive to total assistance with ADLs.
On 08/15/23 at 10:58 a.m., the window was observed in the resident's room to not have any window covering. The resident's room was on the front of the building facility facing the street.
On 08/15/23 at 11:05 a.m., Res #103 stated they did not like the window not being covered but what were they supposed to do about it.
3. Res #110 admitted to the facility and had diagnoses which included schizoaffective disorder and anxiety disorder.
A quarterly assessment, dated 06/04/23, documented the resident was intact with cognition and was independent with ADLs.
On 08/15/23 at 4:36 p.m., the resident's room was observed to not have a curtain or blind, view from the residents room was of the parking lot and the street.
On 08/15/23 at 4:39 p.m., Res #110 stated staff told him they would be putting up curtains, but have not done it yet. Res #110 stated they should put something over the window so people can't see in the room.
4. 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 4:22 p.m., the resident's room was observed to not have a curtain or blind, view from the resident's room was of the parking lot and the street. At this time the resident stated the staff hung the privacy curtain between the beds yesterday but the resident did not know when a window curtain would be put up and it bothered him not to have anything over the window.
5. Res #115 was admitted to the facility and had diagnoses which included non-traumatic intracranial hemorrhage, hemiplegia and hemiparesis, and DM.
An annual assessment, dated 16/17/23, documented the resident was independent with cognitive skills and daily decision making. The assessment documented the resident was total care with most ADLs.
On 08/15/23 at 11:41 a.m., the resident's room was observed to not have a curtain or blind, view from the resident's room was of the parking lot and the street. The resident was asked what happened to the window covering. Res #115 shook their head and shrugged their shoulders they did not know. Res #115 was asked if it bothered them to not have a window covering and the resident shook their head yes.
6. Res #125 was admitted to the facility and had diagnoses which included traumatic brain injury, major depressive disorder, and diabetes mellitus.
A quarterly assessment, dated 06/04/23, documented the resident moderately impaired with cognition and was independent with ADLs.
On 08/16/23 at 9:34 a.m., there were not any kind of window covering observed in the resident's room. At this time the resident stated somebody took the curtains. Res #125 stated they missed having them for privacy and didn't want anyone peeking in on them.
7. Res #127 was admitted the facility and had diagnoses which included anxiety disorder, hallucinations, and osteoarthritis.
An admission assessment, dated 07/20/23, documented the resident was intact with cognition and was independent with ADLs.
On 08/15/23 at 2:48 p.m., the resident's room window was observed to not have curtains or blinds. Res #127 stated the window should have a curtain or blind.
On 08/15/23 at 2:49 p.m., the east hall was observed with one resident room having a window covering. The other seven occupied rooms on the east hall did not have any kind of window covering.
On 08/15/23 at 3:20 p.m., Res #127 stated the facility did have curtains on the window prior to cleaning the rooms. The resident stated the sun shines through the window and there is a glare and the facility should put curtains up.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure OHCA was contacted when residents had serious mental illness...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure OHCA was contacted when residents had serious mental illnesses for two (#101 and #111) of two residents reviewed for PASRR assessments.
The Resident Census and Conditions of Residents form documented 27 residents had documented psychiatric diagnoses.
Findings:
1. Res #101 was admitted to the facility on [DATE] and had diagnoses which included vascular dementia, major depressive disorder, and psychotic disorder.
A PASRR level I, dated 07/27/23, did not document the resident had a serious mental illness and OHCA was not contacted.
A physician order, dated 07/27/23, prescribed Zyprexa (an antipsychotic medication) for the resident.
On 08/16/23 at 3:13 p.m., an interview was conducted with the DON and they stated the hospital informed them a PASRR II was not required for vascular dementia and they had not spoken with anyone from DHS.
2. Res #111 was admitted to the facility on [DATE] and had diagnoses of schizophrenia and recurrent depressive disorder.
A PASRR level I, dated 01/31/23, documented the resident had a serious mental illness and there was no documentation the OHCA was notified.
On 08/17/23 at 4:26 p.m., an interview was conducted with the DON and she stated they did not call OHCA for resident being diagnosed with a serious mental illness.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure colostomy care was provided by professional st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure colostomy care was provided by professional standards of practice for two (#109 and #117) of two residents reviewed for colostomy care.
The Resident Census and Conditions of Residents report, dated 08/15/23, documented two residents with an ostomy.
Findings:
The facility Colostomy/Ileostomy Care Policy documented the staff were to document the date and time the colostomy/ileostomy care was provided. The policy documented the staff were to document the name and title of the individual who provided the colostomy/ileostomy care and any breaks in the resident's skin, signs of infection, or excoriation of skin.
1. Resident #109 was admitted to the facility on [DATE] with diagnoses which included colostomy status and local infections of the skin and subcutaneous tissue.
A skills checklist, dated 07/03/23, for CNA #2 did not document competency for colostomy care or colostomy bag changes.
The annual assessment, dated 07/07/23, documented the resident was moderately impaired for daily decision making, was independent with ADLs, and had a ostomy. The assessment documented the resident had no pressure ulcers, wounds, or skin damage.
The care plan, dated 08/14/22, documented the resident had a alteration in gastro-intestinal status (colostomy). The care plan documented the resident had learned how to empty the colostomy bag on their own and the staff were to provide the resident with a new bag that was cut to fit around their stoma and monitor to ensure no complications with the colostomy bag.
On 08/11/23 at 11:50 a.m., CNA #2 was observed changing the colostomy bag for resident. The bag was leaking a large amount of loose stool from around side of the colostomy bag. CNA #2 pulled the bag off and cleaned the skin area around the stoma. An area of skin close to the stoma was cracked and bleeding. The CNA stated the resident pulls off the bag frequently and requires the bag to be changed. The CNA stated the colostomy was changed at least once a day, which irritated the skin. The CNA started to put a new bag over the irritated skin when the surveyor asked about the irritated skin. The CNA stated she would let the nurse know.
The August 2023 ADL sheet for the resident documented to change the colostomy bag every 72 hours and as needed. The ADL sheet documented check marks and zeros for day, evening, and night shifts since 08/01/23. The ADL sheet did not document the condition of the skin, any skin breakdown, signs of infection, or excoriation of skin.
On 08/17/23 at 2:25 p.m., the DON was asked for skill checks for staff. The DON stated they had not personally conducted skill checks, because everyone was already hired before before taking the DON position. The DON stated they had been employed by the facility since last July 2022, but stated as a charge nurse.
On 08/22/23 at 8:25 a.m., LPN #1 reviewed the TARs for the resident and stated the CNAs have always changed the colostomy bag for the resident. The LPN stated the resident usually required a colostomy bag change daily due to leakage and the resident pulling the bag off. The LPN reviewed the ADL sheet and was unsure what the zeros and check marks represented regarding colostomy bag changes.
2. Resident #117 was admitted to the facility on [DATE] with diagnoses which included impulse disorder, DM, and urinary incontinence.
The MDS assessment, dated 06/04/23, documented the resident was moderately impaired for daily decision making, was independent with most ADLs , and had a ostomy.
The care plan, dated 08/14/23, documented the resident had a colostomy bag due to intestinal issues and the colostomy area would remain clean, dry, and odor free, with no signs of infection. The care plan documented the colostomy bag would be emptied every 72 hours and as needed and colostomy care every shift and as needed.
On 08/17/23 at 10:20 a.m., the resident was observed in the lobby area of the facility. The resident stated the staff changed and maintain his ostomy bag.
On 08/18/23 at 11:00 a.m., NA #3 reviewed the resident's ADL sheet for August 2023. The NA stated they changed the resident's colostomy the day before. The NA stated they had changed the resident's colostomy bag four times this week.
There was no documentation regarding skills checks for NA #3 providing care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to ensure medications were stored in locked compartments.
The Resident Census and Conditions of Residents form dated 08/15/23 documented 27 resid...
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Based on observation and interview the facility failed to ensure medications were stored in locked compartments.
The Resident Census and Conditions of Residents form dated 08/15/23 documented 27 residents resided in the facility.
Findings:
On 08/16/23 at 10:10 a.m., an observation was made of two cabinets storing medications behind the nursing station was opened and unlocked.
On 08/16/23 at 10:11 a.m., an interview was conducted with LPN #1 and they stated the cabinet draws should be closed and locked to prevent any resident from getting into the medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it was determined the facility failed to complete a facility assessment.
The Resident Census and Conditions of Residents form documented 27 residents resid...
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Based on record review and staff interview, it was determined the facility failed to complete a facility assessment.
The Resident Census and Conditions of Residents form documented 27 residents resided in the facility.
Findings:
On 08/15/23 at 8:09 a.m., an entrance conference was conducted with the administrator and the entrance conference worksheet was reviewed. They were made aware of the information required to be submitted from the facility to the survey team. They were provided a copy of a facility assessment template for review.
On 09/12/23 at 3:41 p.m., the DON was asked if she had located the facility assessment. They stated they could not find it anywhere and they had looked all over for the facility assessment form but didn't find it. They also stated the administrator may have the facility assessment form.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected multiple residents
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 ...
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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 consultant, or the administrator's wife would normally report payroll staffing. They also stated they had no idea about a PBJ report.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
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...
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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 days for diagnosis of UTI.
On 08/17/23 at 5:05 p.m., the facility provided a binder titled Antibiotic Stewardship for review. The most recent resident McGreer criteria for infection surveillance checklist was completed 04/26/22. There was no policy or guidance regarding the antibiotic stewardship program.
On 08/17/23 at 5:10 p.m., the charge nurse/LPN #1 stated the assistant administrator stated the only antibiotic stewardship program documentation was provided in the binder. The charge nurse was unaware of a policy for antibiotic stewardship.
On 08/18/23 at 8:17 a.m., the DON stated she was informed yesterday she was responsible for the antibiotic stewardship program as of yesterday. The DON stated they had not been keeping up with the documentation and was unaware of a policy.
On 08/18/23 at 8:20 a.m., the charge nurse/LPN #1 stated the hospice staff was in the facility on 07/20/23 and verbally stated the resident's urine had a strong foul order and would talk to the physician about an antibiotic for the resident. The LPN stated there was no documentation regarding the need for an antibiotic for the resident. The LPN stated sometimes the facility does not know a medication has been ordered for a resident until it arrives from the pharmacy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0949
(Tag F0949)
Could have caused harm · This affected multiple residents
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 documen...
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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. They also state if it is not in the employee file then it was not done. Education and orientation was a complete oversight.
Jun 2023
17 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan for one (#1) of eight residents s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan for one (#1) of eight residents sampled for care plans.
The Resident Census and Conditions of Residents documented 30 residents resided in the facility.
Findings:
Res #1 was admitted on [DATE] with diagnoses of encephalopathy, nontramatic intracerebral hemorrhage in brain stem, convulsions, altered mental status, hypertension, anxiety, and hypokalemia.
Resident #1's clinical record did not include a comprehensive care plan.
On 06/08/23 at 11:02 a.m., RN #1 reported the comprehensive care plan should have been completed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained as free of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazard regarding the use of extension cords for one (#3) of eight sampled residents.
The Resident Census and Conditions of Residents form documented 30 residents resided in the facility.
Findings:
An admission packet document titled, Items not allowed in resident room, read in part, .No extension cords
A facility policy, dated April 2011, read in part, .1. When extension cords are used, the following precautions must be taken: a. Secure extension cords and do not place overhead, under carpets, or where they can cause trips, falls, or overheat. b. Connect extension cords to only one device. 2. Power strips shall not be used as a substitute for adequate electrical outlets in the facility. Power strips may be used for computer, monitor, and printer .
Res #3 was admitted to the facility on [DATE] with diagnoses which included hypertension, paraplegia, cerebral vascular accident, and vascular dementia.
On 06/06/22 at 1:08 p.m., Res. #3's room was observed with a long orange extension cord stretched from the A/C window unit, across an empty bed frame, which was piled with clothing. The cord continued across the floor to the resident's bed by the door, then pulled from underneath the resident's bed frame, and attached to a power strip, which had another power strip plugged into it, which was located between the footboard and mattress of the resident's bed.
On 06/07/23 at 11:16 a.m., the housekeeping supervisor was asked why Res #3 had an orange extension cord from his A/C window unit stretched across the room to a power strip at the end of their bed. The housekeeping supervisor stated we placed the extension cord in Res #3's room for their A/C unit, trying to increase air flow for the west hall.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure residents were offered and had fluids available in their rooms to maintain proper hydration for two (#3 and #4) of eight sampled resid...
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Based on observation and interview, the facility failed to ensure residents were offered and had fluids available in their rooms to maintain proper hydration for two (#3 and #4) of eight sampled residents.
The Resident Census and Conditions of Residents form documented 30 residents who resided in the facility.
Findings:
1. Res #3 had diagnoses which included hypertension, paraplegia, cerebral vascular accident, and vascular dementia.
A quarterly assessment, dated 11/05/22, documented Res #3 was intact in cognition and had no impairments to their upper extremities.
On 06/07/23 at 9:20 a.m., Res #3 was asked if they had fresh water. They stated no, but the CNAs were supposed to pass water and ice three times a day, but they don't. Res #3 was asked how often they received something to drink. They stated, they had to asked the CNAs for a drink and they would get it from the nurse's station sink and the water tastes like mud but it's all we got.
On 06/08/23 at 12:50 p.m., Res #3 was asked if they received fresh water today, they stated no. Res. #3's pink water pitcher was observed empty with a black substance inside the pitcher.
2. Res #4 had diagnoses which included dementia, anxiety, depression, anemia, and hypertension.
On 06/07/23 at 9:28 a.m., Res #4 was asked if they had fresh water. They stated no. Res #4 was asked how often they received something to drink. They stated they had to ask the CNAs for a drink and they don't always bring it.
On 06/07/23 at 10:57 a.m., the SSD was asked when do the CNAs pass fresh water. They stated they were supposed to every shift, but the residents get a drink at 10:00 a.m. in the dining room with snack break. SSD was asked if the bedbound residents received a drink and snack at 10:00 a.m. They stated, No, just the residents who came into the dining room.
No fresh water/ice was observed passed to the resident's during day shift (7 a.m.-3 p.m.) on 06/06/23 or 06/07/23.
On 06/08/23 at 1:11 p.m., Res #4 was asked if he received fresh water today. They stated, No. No water pitcher or cup was observed in Res #4's room.
On 06/08/23 at 1:51 a.m., RN #1 was asked when the CNAs pass fresh water to the residents. They stated they are supposed to pass water at the beginning of every shift. RN#1 was asked if she had seen any CNAs pass fresh water today. They stated they had not.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 06/06/23 at 9:35 a.m., upon entrance into facility, the lobby had a very strong urine odor.
On 06/06/23 at 9:52 a.m., Res ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 06/06/23 at 9:35 a.m., upon entrance into facility, the lobby had a very strong urine odor.
On 06/06/23 at 9:52 a.m., Res #2's air conditioner unit above their bed had several broken pieces of plastic hanging from the unit.
On 06/06/23 at 11:04 a.m., RN #1 was asked how long the facility has had the resident's A/C units. They stated over a year.
On 06/06/23 at 11:28 a.m., Res #8's room had a strong stale urine odor. There was no window screen on window. There were three 5-gallon buckets in resident's bathroom and three solid gel air freshener cones sitting on the resident's toilet lid.
On 06/06/23 at 11:31 a.m., Res #8 was asked why they had three 5-gallon buckets of water in their bathroom. The resident stated, My toilet doesn't work and I use the water to flush my toilet.
On 6/6/23 at 11:32 a.m., Res #8's room was observed with dirt, debris, and dead and alive roaches on the floor. They were asked how often housekeeping cleans his room. They stated, They don't clean my room, I clean my own room.
On 06/06/23 at 11:33 a.m., Res #8 was asked how long his window screen had been missing. Res #8 stated a long time. Two pieces of cut off 2x4 board was observed inside the resident's window. The resident was asked what happened to his window. The resident stated the wind blew their window out and it broke all over the sidewalk. The resident stated they replaced it with the plexi-glass and the pieces of boards keep the plexi-glass from falling out.
On 06/06/23 at 11:47 a.m., Res #4 had a green pad in their wheelchair with a large brown stain in the middle of the pad. Res #4 did not have a screen on their window.
On 06/06/23 at 12:14 p.m., the ambient temperature of the lobby was 85.6 degrees F. There were residents in the lobby.
On 06/06/23 at 12:17 p.m., there was a very strong urine odor in the dining room during the noon meal.
On 06/06/23 at 1:50 p.m., the temperature in the lobby was 86.4 degrees F. There were residents in the lobby.
On 06/06/23 at 3:17 p.m., Res #1's room was observed with an electrical outlet with no cover above the sink and below the mirror. A fan was observed plugged in to the outlet.
On 06/06/23 at 3:32 p.m., Res #3's bathroom toilet was observed with a thick dark black substance inside the toilet tank.
On 06/06/23 at 4:10 p.m., the temperature in the lobby was 89.2 degrees F. There were residents in the lobby.
On 06/07/23 at 9:22 a.m., Res #4's room temperature was 82.6 degrees F.
On 06/07/23 at 10:53 a.m., the housekeeping supervisor was asked if they had a maintenance person. They stated they come in every morning at 7:00 a.m. and look at the maintenance log. They stated if nothing was on the board, they would leave for the day.
On 06/07/23 at 11:03 a.m., the housekeeping supervisor was asked how often housekeeping cleaned the resident's rooms. They stated daily. The housekeeping supervisor was asked if the residents were told to clean their own rooms. They stated not to their knowledge. They stated housekeeping deep cleans the resident rooms monthly and they followed the calendar date matching it to the resident's room number. They stated, Today is the seventh and room seven is being deep cleaned.
On 06/07/23 at 1:02 p.m., during a phone interview with Res #1's representative, they stated there was an electrical outlet by the sink with no cover and they were concerned about.
On 06/07/23 at 2:23 p.m., Res #7 was asked how often housekeeping cleaned his room. They stated they were told to clean their own room.
On 06/07/23 at 3:28 p.m., a sample cup of the facility's tap water was tasted from a pitcher on the medication cart. The water tasted bitter and earthy.
On 06/07/23 at 3:58 p.m., Res #5's room temp was 84.4 degrees F.
On 06/08/23 at 12:58 p.m., Res #3's pink water pitcher sitting on the over the bed table was empty and had a dark black substance on the inside.
On 06/13/23 at 10:42 a.m., the housekeeping supervisor was asked why Res #4 and #5 did not have A/C units installed on Friday. They stated they had to have an electrician here when the A/C company was here to install the A/C units on the north side of the building. They said for now the A/C units were stored in room [ROOM NUMBER]. They were asked how long the facility has had the A/C units in storage. They stated for more than six months.
Based on observation and interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment.
The Resident Census and Conditions of Residents form documented 30 residents resided in the facility.
Findings:
A facility policy, titled ''Floors,'' revised December 2009, reads in part:, .1. All floors shall be mopped/cleaned/vacuumed daily .
1. On 06/08/23 at 9:45 a.m., the bathroom in room [ROOM NUMBER] had an overbearing smell of urine. The tank of the toilet was observed with no lid and a black substance all around the inside of the tank.
On 06/08/23 at 10:05 a.m., the west hall was observed with seven of nine hallway lights not working. The east hall was observed with nine of eight hallway lights not working.
On 06/08/23 at 10:05 a.m., RN #1 reported almost all the hallway lights were not working. They reported it makes it hard to work on night shift.
On 06/13/23 at 11:00 a.m., an observation of all the windows in the resident rooms revealed no screens were present. room [ROOM NUMBER] had a broken window. room [ROOM NUMBER] had a gap between the two windows which was covered with cardboard and duct tape. The gap was opened at the top. room [ROOM NUMBER] was observed with a window air conditioner attached to an extension cord running to an electrical outlet.
On 06/13/23 at 11:48 a.m., Maintenance staff #1 was notified of all the maintenance issues with the building. They reported all the issues should have already been fixed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure comprehensive resident assessments were completed within 14 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure comprehensive resident assessments were completed within 14 days of admission and/or annually for three (#1, 6, and #7) of eight sampled residents whose assessments were reviewed.
The Resident Census and Conditions of Residents form documented 30 residents who resided in the facility.
Findings:
1. Res #6 had diagnoses which included schizoaffective disorder, dementia, and anxiety.
Res #6's clinical record documented the most recent annual assessment had been completed on 04/29/22.
2. Res #7 was admitted on [DATE] and had diagnoses which included schizoaffective disorder, bipolar disorder, and depressive disorder.
Res #7's clinical record documented the admisssion assesssment had been completed on 02/15/22.
The resident records did not contain the annual assessments which were due. 3. Res #1 was admitted on [DATE] with diagnoses of encephalopathy, nontramatic intracerebral hemorrhage in brain stem, convulsions, altered mental status, hypertension, anxiety, and hypokalemia.
Res #1's clinical record did not contain an admission assessment.
On 06/06/23 at 3:02 p.m., RN #1 stated they had begun completing the resident assessments two weeks ago and prior to that no resident assessments had been completed since October or November of 2022.
On 06/12/23 at 2:13 p.m., the DON stated the MDS assessments for all residents were behind because she had not been trained on how to complete them.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to conduct a significant change assessment after an admit to hospice services for
one (#4) of eight sampled residents whose assessments were ...
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Based on record review and interview, the facility failed to conduct a significant change assessment after an admit to hospice services for
one (#4) of eight sampled residents whose assessments were reviewed.
The Resident Census and Conditions of Residents form documented 30 residents who resided in the facility.
Findings:
Res #4 had diagnoses which included dementia, anxiety, depression, anemia, and hypertension.
On 06/07/23 at 3:42 p.m., the hospice nurse stated Res #4 was admitted to hospice services on 03/02/23.
The resident's medical record did not contain a significant change assessment.
On 06/06/23 at 3:02 p.m., RN #1 stated they had begun completing resident assessments with significant changes two weeks ago and prior to that no resident assessments have been completed since October or November of 2022.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
3. Res #3's clinical records documented an annual assessment, dated 11/05/22.
The resident's record did not contain a quarterly assessment since the annual assessment in November 2022.
4. Res #4's cl...
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3. Res #3's clinical records documented an annual assessment, dated 11/05/22.
The resident's record did not contain a quarterly assessment since the annual assessment in November 2022.
4. Res #4's clinical records document the most recent assessment was an annual assessment, dated 08/29/22.
The resident's record did not contain a quarterly assessment since the annual assessment in August 2022.
5. Res #5's clinical records documented the most recent resident assessment was an annual dated 10/21/22.
The resident's record did not contain a quarterly assessment since the annual assessment in October 2022.
6. Res #8's clinical records documented an annual assessment, dated 09/29/22.
The resident record did not document a quarterly assessment after the assessment in September 2022.
On 06/06/23 at 3:02 p.m., RN #1 stated they began completing resident assessments two weeks ago and prior to that no resident assessments had been completed since October or November of 2022.
On 06/12/23 at 2:20 p.m., the DON stated the assessments had not been completed.
Based on record review and interview, the facility failed to complete a resident assessment at least quarterly for six (#2, 3, 4, 5, 6, and #8) of eight residents whose assessments were reviewed.
The Resident Census and Conditions of Residents form documented 30 residents resided in the facility.
Findings:
1. Res #6's medical record documented a annual assessment, dated 04/29/22.
The resident's record did not contain a quarterly assessment since the quarterly, dated 10/30/22. 2. Res #2's medical record documented a quarterly assessment, dated 09/16/22.
The resident's record did not contain a quarterly assessment since the quarterly in September 2022.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
3. Res #3 had diagnoses which included hypertension, paraplegia, cerebral vascular accident, and vascular dementia.
Res #3's clinical record documented a resident assessment had not been completed or ...
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3. Res #3 had diagnoses which included hypertension, paraplegia, cerebral vascular accident, and vascular dementia.
Res #3's clinical record documented a resident assessment had not been completed or transmitted since 11/05/22.
4. Res #4 had diagnoses which included dementia without behavioral disturbances, anxiety, depression, anemia, and hypertension.
Res #4's clinical record documented a resident assessment had not been completed or transmitted since 08/29/22.
5. Res #5 had diagnoses which included schizoaffective disorder, bipolar disorder, anxiety, mild intellectual disability, and diabetes.
Res #5's clinical record documented a resident assessment had not been completed or transmitted since 10/21/22.
6. Res #8 had diagnoses which included hypertension, restrictive cardiomyopathy, myocardial infarction, presence of cardiac defibrillator, personality change due to known physiological condition, cardiac arrest, and respiratory arrest.
Res #8's clinical record documented a resident assessment had not been completed or transmitted since 09/29/22.
On 06/06/23 at 3:02 p.m., RN #1 was asked who was responsible for completing and submitting the resident assessments. They stated they began completing resident assessments two weeks ago and prior to that no resident assessments have been completed since October or November of 2022.
On 06/12/23 at 2:27 p.m., the DON reported the resident assessments had not been completed or transmitted but should have been.
Based on record review and interview, the facility failed to ensure resident assessments were transmitted to CMS within seven days of completion for six (#3, 4, 5, 6, 7, and #8) of eight sampled residents whose assessments were reviewed.
The Resident Census and Conditions of Residents form documented 30 residents resided in the facility.
Findings:
1. Res #6 had diagnoses which included schizoaffective disorder, dementia, and anxiety.
Res #6's clinical record documented a resident assessment had not been completed or transmitted since 10/30/22.
2. Res #7 had diagnoses which included bipolar disorder, schizoaffective disorder, and depressive disorder.
Res #6's clinical record documented a resident assessment had not been completed or transmitted since 11/18/22.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
4. Res #3 had diagnoses which included hypertension, paraplegia, cerebral vascular accident, and vascular dementia.
A care plan, dated 05/09/21, did not reveal a review/revision had been conducted si...
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4. Res #3 had diagnoses which included hypertension, paraplegia, cerebral vascular accident, and vascular dementia.
A care plan, dated 05/09/21, did not reveal a review/revision had been conducted since 05/09/21.
5. Res #4 had diagnoses which included dementia without behavioral disturbances, anxiety, depression, anemia, and hypertension.
A care plan, dated 08/13/22, did not reveal a review/revision had been conducted since 08/13/22.
6. Res #5 had diagnoses which included schizoaffective disorder, bipolar disorder, anxiety, mild intellectual disability, and diabetes.
A care plan, dated 05/09/21, did not reveal a review/revision had been conducted since 05/09/21.
7. Res #8 had diagnoses which included hypertension, restrictive cardiomyopathy, myocardial infarction, presence of cardiac defibrillator, personality change due to known physiological condition, cardiac arrest, and respiratory arrest.
On 06/06/23 at 3:05 p.m., RN #1 stated the care plans should have been reviewed and revised.
Based on observation, record review, and interview, the facility failed to ensure residents' care plans were reviewed for seven (#2, 3, 4, 5, 6, 7, and #8) of eight sampled residents whose care plans were reviewed.
The Resident Census and Conditions of Residents documented 30 residents resided in the facility.
Findings:
A facility policy titled Care Plans - Comprehensive, dated December 2010, read in part: .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly .
1. Res #6 had diagnoses which included schizoaffective disorder, dementia, and anxiety.
On 06/12/23 at 1:30 p.m., Res #6 was observed ambulating independently in the facility lobby. The resident was observed as calm and alert. Res #6 stated no concerns with care.
On 06/12/23, Res #6's care plan documented the target date for plan of care goals as 11/12/22. There was no documentation the care plan had been reviewed since this date.
2. Res #7 had diagnoses which included schizoaffective disorder, bipolar disorder, and depressive disorder.
On 06/12/23 at 1:40 p.m., Res #7 was observed sitting on the side of their bed drawing a picture. The resident was observed as calm and alert. Res #7 stated the facility provided assistance with their needs.
Res #7's care plan documented the plan of care target date for goals as 11/12/22. There was no documentation the care plan had been reviewed since this date.
On 06/12/23 at 2:35 p.m., the DON stated the care plan for Resident #6 and Resident #7 had not been reviewed since their last comprehensive resident assessment but should have been.
3. Res #2 had diagnoses of chronic pancreatitis, hypokalemia, dysphasia, diabetes mellitus, and emphysema.
A care plan, dated 08/14/22, did not reveal a review/revision had been conducted since 08/14/22.
On 06/08/23 at 11:02 a.m., RN #1 reported the care plan should have been reviewed or revised.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
3. Res #3 had diagnoses which included vascular dementia with behavioral disturbances, dysthymic disorder, and schizophrenia.
A quarterly resident assessment, dated 11/05/22, documented Res #3 was in...
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3. Res #3 had diagnoses which included vascular dementia with behavioral disturbances, dysthymic disorder, and schizophrenia.
A quarterly resident assessment, dated 11/05/22, documented Res #3 was intact in cognition and received antipsychotic and antidepressant medications daily during the assessment period. The assessment documented a GDR had not been attempted.
MRRs could not be provided for September 2022 through December 2022 for Res #3.
4. Res #4 had diagnoses which included dementia, anxiety, and depression.
A quarterly resident assessment, dated 08/29/22, documented the resident received antipsychotic and antidepressant medications daily during the assessment period. The assessment documented a GDR had not been attempted.
MRRs could not be provided for September 2022 through December 2022 for Res #4.
5. Res #5 had diagnoses which included schizoaffective disorder, bipolar disorder, anxiety, and mild intellectual disability.
A quarterly resident assessment, dated 08/29/22, documented the resident received antipsychotic and antidepressant medications daily during the assessment period. The assessment documented a GDR had not attempted.
MRRs could not be provided for September 2022 through December 2022 for Res #5.
On 06/06/23 at 3:12 p.m., RN #1 reported the consultant pharmacist MRR's for September 2022 through December 2022 for Res #3, 4, and #5 could not be located in the facility.
Based on observation, record review, and interview, the facility failed to ensure the consultant pharmacist conducted monthly medication reviews routinely for five (#3, 4, 5, 6, and #7) of five residents sampled for unnecessary medications.
The Resident Census and Conditions of Residents form documented 18 residents received psychoactive medications in the facility.
Findings:
1. Res #6 had diagnoses which included schizoaffective disorder, anxiety disorder, and extrapyramidal and movement disorder.
A quarterly resident assessment, dated 10/30/22, documented the resident was intact in cognition and received antipsychotic and antidepressant medications daily during the assessment period. The assessment documented a GDR had not been attempted.
On 06/12/23 at 1:30 p.m., Res #6 was observed ambulating independently in the facility lobby. The resident was observed as calm and alert. Res #6 stated no concerns with care or medications.
The consultant pharmacist MRR forms for Res #6 were reviewed from 01/25/23 through 05/31/23. The facility was unable to locate the September 2022 through December 2022 MRR reports upon request.
2. Res #7 had diagnoses which included paraphilia, impulse disorder, and schizoaffective disorder.
A quarterly assessment, dated 11/18/22, documented the resident received antipsychotic and antidepressant medications daily during the assessment period. The assessment documented a GDR had not been attempted.
The consultant pharmacist MRR forms for Res #7 were reviewed from 01/25/23 through 05/31/23. The facility was unable to locate the September 2022 through December 2022 MRR reports upon request.
On 06/12/23 at 1:40 p.m., Res #7 was observed sitting on the side of their bed drawing a picture. The resident was observed as calm and alert. Resident #7 stated they did not know why they received so many medications.
On 06/12/23 at 2:50 p.m., the DON reported the consultant pharmacist MRR's for September 2022 through December 2022 for Res #6 and Res #7 could not be located in the facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to monitor for resident behaviors and side effects of psychotropic medications and ensure residents received gradual dose reduct...
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Based on observation, record review, and interview, the facility failed to monitor for resident behaviors and side effects of psychotropic medications and ensure residents received gradual dose reductions for two (#6 and #7) of five residents reviewed for unnecessary medications.
The Resident Census and Conditions of Residents documented 18 residents received psychotropic medications.
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 practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible .
A facility policy titled Tapering Medications and Gradual Drug Dose Reductions, dated April 2007, read in part, .Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue to these drugs .
1. Resident #6 had diagnoses which included dementia with behavioral disturbances, schizoaffective disorder, anxiety disorder, and extrapyramidal and movement disorder.
A physician order, dated 08/04/18, documented the facility was to monitor for behaviors and side effects of antipsychotic medications.
A care plan, last revised on 08/19/18, documented the resident had the potential to be verbally aggressive related to disease process. The care plan documented the resident used psychotropic medications related to behavior management with an intervention to monitor for side effects and effectiveness every shift.
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, documented the facility was to administer Geodon (an antipsychotic medication) 80 mg capsule every twelve hours for a diagnosis of schizoaffective disorder.
A physician order, dated 10/13/22, documented the facility was to administer Zyprexa (an antipsychotic medication) 5 mg at bedtime for a diagnosis of schizoaffective disorder.
A quarterly resident assessment, dated 10/30/22, documented the resident was intact in cognition and received antipsychotic and antidepressant medications daily during the assessment period. The assessment documented a GDR was not attempted.
A physician order, dated 11/16/22, documented the facility was to administer Vraylar (an antipsychotic medication) 3 mg daily for a diagnosis of schizoaffective disorder.
Behavior monthly flow sheets were reviewed for March 2023, April 2023, May 2023, and June 2023. No additional documentation of behavior monitoring prior to March 2023 was provided by the facility.
The consultant pharmacist MRR forms for Res #6 were reviewed from 01/25/23 through 05/31/23. The MRR forms did not document any recommendation from the pharmacist to the physician to review the use of psychotropic medications for possible GDR. The facility was unable to locate the September 2022 through December 2022 MRR reports upon request.
On 06/12/23 at 1:30 p.m., Res #6 was observed ambulating independently in the facility lobby. The resident was observed as calm and alert. Res #6 stated no concerns with care or medications.
On 06/12/23 at 3:00 p.m., the DON stated behavior monitoring was not documented consistently prior to March 2023. The DON stated they documented an occasional nurse note on Res #6 but did not document behaviors or monitoring of side effects regularly.
2. Res #7 had diagnoses which included paraphilia, impulse disorder, and schizoaffective disorder.
A physician order, dated 09/01/16, documented the facility was to administer Invega (an antipsychotic medication) 3 mg daily and 6 mg at bedtime for a diagnosis of schizoaffective disorder.
A physician order, dated 08/04/18, documented to monitor for behaviors and side effects of antipsychotic medications.
A care plan, last revised 07/01/21, documented the resident had the potential to be physically aggressive related to poor impulse control. The care plan documented the resident used psychotropic medications related to behavior management with an intervention to consult with pharmacy and the physician would consider dosage reduction when clinically appropriate and at least quarterly. The care plan documented an intervention to monitor and document side effects and effectiveness every shift.
A physician order, dated 01/26/20, documented the facility was to administer Celexa (an antidepressant medication) 5 mg daily for a diagnosis of schizoaffective disorder.
A physician order, dated 06/04/21, documented the facility was to administer Depakote (an anti-siezure medication) 1000 mg daily and 1250 mg at bedtime for a diagnosis of impulse disorder.
A physician order, dated 09/21/22, documented the facility was to administer Vraylar (an antipsychotic medication) 3 mg daily for a diagnosis of schizoaffective disorder.
A physician order, dated 10/13/22, documented the facility was to administer clozapine (an antipsychotic medication) 75 mg daily and 100 mg at bedtime for a diagnosis of schizoaffective disorder.
A quarterly assessment, dated 11/18/22, documented the resident was cognitively intact and received antipsychotic and antidepressant medications daily during the assessment period. The assessment documented a GDR was not attempted.
Behavior monthly flow sheets for May 2023 and June 2023 were reviewed. No additional documentation of behavior monitoring prior to May 2023 was provided by the facility.
There was no documentation of antidepressant side effect monitoring found in the medical record.
The consultant pharmacist MRR forms for Res #7 were reviewed from 01/25/23 through 05/31/23. The MRR forms did not document any recommendation from the pharmacist to the physician to review the use of psychotropic medications for possible GDR. The facility was unable to locate the September 2022 through December 2022 MRR reports upon request.
On 06/12/23 at 1:40 p.m., Res #7 was observed sitting on the side of their bed drawing a picture. The resident was observed as calm and alert. Res #7 was asked about any concerns with their medications. They stated they did not know why they received so many medications.
On 06/12/23 at 2:50 p.m., the DON reported the consultant pharmacist MRR's for September 2022 through December 2022 for Res #6 and Res #7 could not be located in the facility. The DON stated there was no way to know if a GDR had been requested or not during this time frame. They stated they were not being aware of the MRR or GDR policy because they had never been trained on the process. The DON stated there was no way to prove a GDR had been requested or attempted for Res #6 or Res #7 with the documentation that currently existed within the facility.
On 06/12/23 at 3:00 p.m., the DON stated they were not aware of psychotropic medication side effect monitoring was not being documented for Res #7. The DON stated behavior monitoring was not documented consistently prior to March 2023. The DON stated they documented an occasional nurse note on Res #7 but did document behaviors or the monitoring of side effects regularly.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure three trash dumpsters were maintained to keep pests out and/or to keep the refuse contained in the dumpsters.
The Resident Census and...
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Based on observation and interview, the facility failed to ensure three trash dumpsters were maintained to keep pests out and/or to keep the refuse contained in the dumpsters.
The Resident Census and Conditions of Residents documented 30 residents resided in the facility.
Findings:
On 06/08/23 at 11:45 a.m., three large green trash dumpsters were observed directly behind the facility. Two of the three lids on the dumpsters were open. Bags of refuse and cardboard boxes were observed sticking out of the top of the open dumpsters. Numerous flies were observed on and around the dumpsters. A malodorous smell was noted. A gray cat was observed walking around the dumpsters. The cat attempted to enter the open dumpsters during the observation period.
On 06/12/23 at 8:50 a.m., three dumpsters were observed with the lids open. Bags of refuse and cardboard boxes were observed sticking out of the top of the dumpsters. Rain water was observed inside the open lids and down within the bottom of the dumpsters. Numerous flies were observed on and around the dumpsters. A malodorous smell was noted.
On 06/13/23 at 11:27 a.m., three dumpsters were observed with the lids open. Rain water was observed inside the open lids and down within the bottom of the dumpsters. Numerous pieces of wet cornbread were observed in the bottom of one of the three dumpsters. Numerous flies were observed on and around the dumpsters. A gray cat was observed attempting to enter the dumpster that contained the wet cornbread. A malodorous smell was noted.
On 06/13/23 at 11:50 a.m., the DON was asked to observe the trash dumpsters. The DON stated the lids to the dumpsters should always be closed to decrease the smell and pests.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure proper handwashing.
The Resident Census and Conditions of Residents form documented 30 residents resided in the facility.
Findings:
A ...
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Based on observation and interview, the facility failed to ensure proper handwashing.
The Resident Census and Conditions of Residents form documented 30 residents resided in the facility.
Findings:
A facility hand washing policy, revised April 2012, documented all personnel shall follow the handwashing/hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy documented employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water.
On 06/06/23 at 10:34 a.m., the common bathroom located in the lobby contained a sink which only had hot water. The sink did not have cold water. The temperature of the water was 128 degrees F.
On 06/06/23 at 2:05 p.m., the sink at the nurse's station was observed to have two 1-gallon pitchers of water, one on each side of the sink. The hot water temperature was 140.4 degrees F. The water temperature with both the cold and hot water on together was 138.8 degrees F.
On 06/06/23 at 4:14 p.m., the employee restroom beside the nurse's station did not have a working sink. The sink was disconnected and pulled away from the wall with a brown waste basket between the wall and the sink.
On 06/07/23 at 9:53 a.m., CNA #1 was asked how long the employee bathroom, beside the nurse's station, had been without a sink. They stated, Awhile, I really don't remember.
On 06/07/23 at 10:28 a.m., CNA #1 was asked how they ensured they performed proper handwashing. CNA #1 stated they came out of the bathroom to the nurse's station sink to wash their hands. They stated the hot water did not bother them. CNA #1 was asked if they were able to wash their hands for a full fifteen seconds with a water temperature of 140 degrees F. They stated, No.
On 06/07/23 at 10:50 a.m., CNA #3 was asked how they ensured they performed proper handwashing. They stated they used the sink at the nurse's station to wash their hands. They stated they put soap on their hands, wet their hands with the hot water, and used the water from one of the water pitchers sitting at the sink to rinse their hands. CNA #3 was asked if they were able to wash their hands for a full fifteen seconds with the water temperature of 140 degrees F. They stated, No.
On 06/07/23 at 11:14 a.m., the housekeeping supervisor was asked how long the sink in the employee's bathroom, beside the nurse's station, had been without a sink. They stated the sink was disconnected 05/30/23 due to a water leak inside the wall. The housekeeping supervisor was asked how the staff ensured they have performed proper handwashing. They stated they used the nurse station sink to wash their hands and used the water from one of the water pitchers sitting at the sink to rinse their hands. The housekeeping supervisor was asked if they were able to wash their hands for a full fifteen seconds with the water temperature of 140.4 degrees F. and they stated, No.
06/07/23 at 11:22 a.m., the housekeeping supervisor was asked how long the lobby employee/visitor bathroom had only hot water and no cold water. They stated they were not aware the bathroom did not have cold water.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident call lights were within reach for three (#1, 3 and #4...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident call lights were within reach for three (#1, 3 and #4) of eight sampled residents observed for call lights.
The Resident Census and Conditions of Residents form documented 30 residents resided in the facility.
Findings:
1. Res #1 was admitted on [DATE] with diagnoses of encephalopathy, nontramatic intracerebral hemorrhage in brain stem, convulsions, altered mental status, and anxiety.
On 06/06/23 at 10:18 a.m., Res #1's call light was observed on the floor at the end of their bed.
On 06/06/23 at 10:22 a.m., Res #1's call light was tested for functioning. Res #1's call light bulb above their door entering into their room was not lit. RN #1 entered the resident's room and stated Res #1's call light did not work. RN #1 stated they could hear a buzzer at the nurse station but it did not indicate which resident room was needing assistance.
On 06/07/23 at 8:42 a.m., Res #1's call light was observed on the floor at the end of their bed.
2. Res #3's quarterly assessment, dated 11/05/22, documented their cognition was intact and had no impairments to their upper extremities and had impairment to their lower extremities.
On 06/06/23 at 10:10 a.m., Res #3's call light was observed on the floor at the end of their bed.
On 06/06/23 at 11:56 a.m., Res #3's call light was observed on the floor at the end of their bed.
On 06/07/23 at 2:10 p.m., Res #3's call light was observed on the floor at the end of their bed.
On 06/07/23 at 2:15 p.m., Res #3 was asked how long their call light had been on the floor. They stated it was rarely within their reach. They stated they called out loudly for the nurse aides and sometimes they would respond and sometimes they did not.
3. Res #4's quarterly assessment, dated 08/29/22, documented the resident was intact in cognition and had no impairments to their upper extremities and impairment to their lower extremities.
On 06/06/23 at 3:55 p.m., Res #4's call light was observed on the floor at the end of their bed, between the wall and the bed.
On 06/07/23 at 9:39 a.m., Res #4's call light was observed on the floor at the end of their bed, between the wall and the bed.
Res #4 was asked how long their call light had been at the end of the their bed. They stated it was always there.
On 06/06/23 at 3:09 p.m., RN #1 was asked if the call lights should be within the residents' reach. They stated the CNAs should be ensuring the call lights were within reach and functioning properly. RN #1 was asked if Res #1, 3, and #4's call lights were within the their reach. They stated, No.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0922
(Tag F0922)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure water was available to essential areas.
The Resident Census and Conditions of Residents form documented 30 residents resided in the fa...
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Based on observation and interview, the facility failed to ensure water was available to essential areas.
The Resident Census and Conditions of Residents form documented 30 residents resided in the facility.
Findings:
On 06/06/23 at 10:34 a.m., the employee/visitor/resident lobby bathroom commode was observed with dark yellow water in the commode and the tank lid was missing. The toilet did not flush and the bathroom sink did not have cold water, only hot.
On 06/06/23 at 11:28 a.m., Res #8's bathroom was observed to have three 5-gallon buckets of water in their bathroom.
On 06/06/23 at 11:31 a.m., Res #8 was asked what the buckets of water were for in his bathroom. The resident stated, My toilet doesn't work and I use the water to flush my toilet.
On 06/06/23 at 4:14 p.m., the employee restroom beside the nurse station did not have a working sink. The sink was disconnected and pulled away from the wall, which left a large hole in the wall.
On 06/07/23 at 9:53 a.m., CNA #1 was asked how long the sink in the employee bathroom beside the nurse station had been without a sink. They stated, Awhile, I really don't remember.
On 06/07/23 at 10:53 a.m., the housekeeping supervisor was asked if the facility had a maintenance person. They stated, yes, he came in every morning at 7:00 a.m. and looked at the maintenance log and if nothing was on the board he would leave for the day.
On 06/07/23 at 1:14 p.m., the housekeeping supervisor was asked how long the sink in the employee's bathroom beside the nurse station had been without a sink. They stated the sink was disconnected 05/30/23 due to a water leak inside the wall.
06/07/23 at 1:16 p.m., the housekeeping supervisor was asked how long the lobby employee/visitor bathroom had been without cold water and only hot water. They stated they were not aware the lobby bathroom did not have cold water.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to maintain an effective pest control program so that the facility was free of roaches.
The Resident Census and Conditions of Re...
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Based on observation, record review, and interview, the facility failed to maintain an effective pest control program so that the facility was free of roaches.
The Resident Census and Conditions of Residents documented 30 residents resided in the facility.
Findings:
On 06/06/23 at 10:34 a.m., the employee/guest/resident lobby bathroom was observed to have live roaches crawling on the sink and toilet lid.
On 06/06/23 at 11:12 a.m., Res #2's bathroom was observed to have four live roaches crawling on the floor. The resident's urinal was observed at bedside with two live roaches crawling on it.
On 06/06/23 at 11:32 a.m., Res #8's room was observed with dirt, debris, and dead and alive roaches on the floor. They were asked how often housekeeping cleaned their room. They stated, They don't clean my room, I clean my own room.
On 06/06/23 at 2:12 p.m., during an interview with Res #3, roaches were observed crawling on the base board by the closet.
On 06/12/23 at 12:44 p.m., the housekeeping supervisor provided receipts from the pest control company for April and May 2023. Zenoprox was one of the insecticides documented on the receipts. They were asked if the current pest control was effective. They reported that it was not.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, record review, and interview, the facility failed to be administered effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial ...
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Based on observation, record review, and interview, the facility failed to be administered effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The administration failed to ensure:
a. resident call lights were within reach of residents.
b. a safe, clean, comfortable, homelike environment was provided.
c. comprehensive assessments were completed within 14 days of admission and annually.
d. quarterly assessments were completed every three months.
e. resident assessments were transmitted to CMS within seven days of completion.
f. comprehensive care plans were developed.
g. resident care plans were reviewed and updated.
h. extension cords were used in a safe manner.
i. residents had sufficient fluid intake to maintain proper hydration and health.
j. the consultant pharmacist requested GDRs related to psychotropic medications.
k. monitor for behaviors and side effects of psychotropic medications.
l. three trash dumpsters were maintained to keep pests out and/or to keep the refuse contained in the dumpsters.
m. proper handwashing facilities.
n. water was available to essential areas.
o. an effective pest control program was maintained so that the facility was free of roaches.
The Resident Census and Conditions of Residents form documented 30 residents who resided in the facility.
Findings:
On 06/06/23 at 9:45 a.m., an entrance conference was conducted with RN #2. The RN was asked if they were the DON, they stated, No, I'm in transition and in training. They stated, RN #1 was the part-time DON and the owner's daughter (assistant administrator) was the acting DON. RN #2 was asked for an alphabetical resident list. They stated the electronic health record was a new system for the facility. RN #2 stated they had not been trained on the the electronic record system.
On 06/06/23 at 1:17 p.m., the assistant administrator was asked who the DON of the facility was. They stated the DON was RN #2. The assistant administrator was asked if RN #1 was a part-time DON. They stated, No, RN #1 was just helping out with the MDSs. The assistant administrator was asked if they were the acting DON. They stated absolutely not. The assistant administrator was asked if the DON was trained for the position. They stated, Yes, I trained her myself. I worked side by side with her for six months. The assistant administrator was asked when the facility started utilizing the electronic health record system. They stated in 2013. The assistant administrator was asked if they trained the DON on the record system. They stated they had. The assistant administrator was asked what their role was in the facility. They stated they were the administrator's/owner's daughter. They stated the administrator was out with poor health and she also had a job as a nurse practitioner at two other facilities. They stated, I am just trying to hold this place together until we sell it.
On 06/07/23 at 10:57 a.m., the human resources director was asked who the DON of the facility was. They stated RN #2.
The employee roster identified RN #2 as the DON, with a hired date of 07/06/22.
On 06/13/23 at 12:42 p.m., during a telephone interview the assistant administrator was asked how they ensured the facility was operated effectively in the absence of the administrator. They stated the administrator may appoint the assistant administrator, the DON, or follow their chain of command to handle situations in the facility. The assistant administrator stated, I am in the facility once every two weeks to run payroll. The assistant administrator was asked if they had been appointed by the administrator to ensure the facility was operated effectively. They stated, No, the DON was. The assistant administrator was asked how they ensured the day-to-day functions of the facility. They stated the part owner was in the facility weekly and they call me weekly with an update. They stated when the administrator experienced their stroke, they looked at their policy, and it said when the administrator was unavailable, they may appoint the assistant administrator or the DON to handle situations in the facility.
A facility policy, titled Administrator, revised April 2007, read in part, .In the absence of the Administrator, the Assistant Administrator, or the DON of nursing services is authorized to act in the Administrators behalf .
On 06/13/23 at 8:40 a.m., the part owner of the facility stated he did not have a bachelor's degree so they would not be in an administrative capacity. The part owner stated he was going to be checking on things at the facility more often.
On 06/13/23 at 2:16 p.m., an exit conference was conducted with the human resources director/dietary manager/housekeeping supervisor, the DON, and the part owner via cell phone. Upon the conclusion of the exit conference the part owner stated they would be in the facility checking on things daily.
May 2022
12 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An Immediate Jeopardy (IJ) situation was determined to exist effective [DATE] based upon the facility's failure to immediately c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An Immediate Jeopardy (IJ) situation was determined to exist effective [DATE] based upon the facility's failure to immediately contact EMS when CPR was initiated for Res #26 with a full code status who was found not breathing and without a detectable heart beat.
On [DATE] at 11:21 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 11:26 a.m., the administrator was notified of the IJ situation.
On [DATE] at 1:38 p.m., an acceptable plan of removal was provided. The plan of removal documented:
''Rainbow Terrace Care Center Immediate Jeopardy Plan for Removal [DATE].
On [DATE], a resident was found to not have viable vital signs, resulting in CPR being initiated. Although the Charge Nurse directed for someone to call 9-1-1, there is no documentation to support a call being made. After 25 minutes of CPR being performed, Dr. [name withheld] called time of death. While it is unknown if EMS would have arrived or transferred the resident to the nearest Emergency Room, the fact remains that there is no evidence of the call being placed. It is the responsibility of the charge nurse to initiate CPR and all actions of the Police and Procedure be followed.
Step 1 of ensuring the Policy and Procedure is followed is ensuring that there is a designated team per shift. The charge nurse is responsible for initiating CPR and leading the code. The Certified Medication Aide on day and evening shifts is responsible for verifying the code status of the resident, reporting to the nurse aid calling 9-1-1. On Midnight shift, the East Hall Certified Nurse Aide is responsible for determining the code status based on the red or green dots on the outside of the charts, and calling 9-1-1 for emergency services. While this action is being completed, the charge nurse will initiate CPR, using the BLS sequences of events. CPR will be performed until EMS arrives and leaves with the resident or receives the official time of death verification.
Once the plan of removal has been approved by the State Department of Health, All staff will be immediately in-serviced in person/by telephone and verbally acknowledge the system in place. This is expected to be completed within 4 hours of approval.
To further this process, the facility will contact the American Red Cross or the American Heart Association and set up a time for staff to become BLS certified at the cost of the facility. To ensure that new staff are aware of this team-oriented approach, new hires will be educated at the time of hire to ensure understanding. The facility will educate all staff on this process every 3 months from now on. The Director of Nursing will monitor understanding of the process and ensure that it is completed when notified that CPR had been performed.'' This form was signed by the DON and dated [DATE].
A document entitled, IJ Plan of Removal Staff Contacts documented a staff sign-in list with the last staff member in-serviced at 2:42 p.m.
On [DATE] interviews were conducted with nursing staff regarding education and in-service information pertaining to the IJ plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal.
On [DATE] at 3:30 p.m., the DON was informed the IJ was lifted at [DATE] at 2:42 p.m. The deficiency remained at the level of actual harm.
Based on record review and interview, the facility failed to provide EMS services for one (#26) of four residents sampled for death in facility.
The ''Resident Census and Conditions of Residents'' report documented 33 residents resided in the facility.
Findings:
Res #26 was admitted to the facility on [DATE] and had diagnoses which included hypertension, edema, cerebrovascular disease, and dementia.
A physician order, dated [DATE], documented the resident had a full code status.
An advanced directive, dated [DATE], documented the resident wanted hydration, nutrition and life sustaining treatment.
A quarterly assessment, dated [DATE], documented the resident was moderately impaired with cognition and required extensive assistance with most activities of daily living.
A nurse note, dated [DATE] at 7:00 p.m., documented Res #26 continued sitting in the recliner resting with eyes closed and oxygen at 2 L per NC and responded to stimuli.
A nurse note, dated [DATE] at 8:00 p.m., documented Res #26 was in the recliner with oxygen in place at 2 L per NC. The note documented temp 102.8, resp 30, P 59, and SpO2 75%. The note documented the nurse told the resident she was going to call the physician and send Res #26 to the ER. The note documented Res #26 refused and stated, No three times.
A nurse note, dated [DATE] at 8:30 p.m., documented in parts .called to R's room the resident was non-responsive, unable to palpate pulse, no breath sounds, R was put on floor CPR initiated, black fluid filling mouth head turned to side, copious amount of dark fluid cont to pour out of mouth and nose CPR continued for 35 min, contacted Dr. [name removed], time of death 2105 .Contacted funeral home [name withheld] for pick-up. Called [name withheld] friend of resident .2215 [name withheld] funeral home left with R.
On [DATE] at 4:23 p.m., the DON stated she did not see where 911 was called in the nurse notes. She stated you call 911 anytime CPR is started.
On [DATE] at 4:40 p.m., LPN #1 stated she did not call EMS. She stated she thought someone else was calling EMS. She stated when she was relieved by another staff member who continued CPR for the resident, she went up to call the physician and by that time it had been at least 35 minuets and EMS had not shown so she was not sure if EMS had been called.
On [DATE] at 9:47 a.m., CNA #4 stated she worked weekend doubles but was not working when the resident passed. She stated last time she worked Res #26 was fine but not eating well. She stated he was talking and he was able to stand with help. She stated the facility had in-services but not a CPR in-service on what to do with a full code. She stated she was not sure what to do and had not had to help with a full code. She stated she was not CPR certified.
On [DATE] at 9:58 a.m., CNA #3 stated he was present the night the resident passed away. CNA #3 stated CMA #1 found Res #26 and hollered at the nurse and him. CMA #3 stated they went into full code. CMA #3 stated the nurse started doing CPR and then asked me if I could take over. He stated he was CPR certified. CNA #3 stated he did not think anyone called EMS.
ON [DATE] at 10:15 a.m., CMA #1 stated she had worked at the facility at least 10 years. She stated she was working the night Res #26 passed away. She stated she was not able to perform CPR. She stated she normally would get the paperwork together and call 911. She stated she honestly could not remember if she called the ambulance but if it had been called it would have been her that called.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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 recor...
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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 stated the care plan for Res #13 had not been done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
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 re...
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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 came back a few minutes later and stated she had told the DON. The resident stated he did not like to lie on his right side.
On 05/12/22 at 12:25 p.m., the resident stated no one had medicated or dressed his sore on his ankle.
The medical record was reviewed and there was no assessment or treatment order for the pressure ulcer. There was no indication the physician had been notified.
On 05/12/22 at 12:31 p.m., the DON was asked about her knowledge of the resident's pressure ulcer and she said LPN #2 was supposed to have gone down and looked at it. She said she would call and get an order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
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 t...
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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 appointment to be seen by a dentist. Res #13 indicated a right lower tooth.
On 05/12/22 at 4:34 p.m., the DON stated Res #13 had asked for the sore tooth to be filled. The DON stated it was the experience of the facility that Medicaid residents in a nursing home would not be provided any service but tooth extraction for a cavity. The DON stated Res #13 did not want the tooth pulled so she did not make an appointment for an evaluation by the dental services utilized by the facility.
On 05/16/22 a review of Res #13's clinical record did not contain a care plan.
On 05/16/22 at 2:25 p.m., the local dental service, identified by the facility as one dentist service they used, was contacted regarding treatment of Medicaid residents who resided in a facility. The dental service stated they would do a filling if needed and if the resident could come to the dental office.
On 05/16/22 at 2:57 p.m., the SSD stated they made the appointments for services needed by residents. The SSD stated Res #13 did not want the sore tooth extracted.
On 05/16/22 at 3:07 p.m., the SSD stated she called the dental service and was told to contact Medicaid to see what would be covered. The SSD stated the facility would re-contact the dental service and make an appointment for Res #13 and the dental service could explain what would be covered.
On 05/17/22 at 4:44 p.m., the administrator stated if a resident is complaining of tooth pain a dental appointment should have been made and the dental office should have explained any treatment options to the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**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 comple...
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**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 diagnoses which included anxiety disorder, dementia with behavioral disturbances, and high risk heterosexual behavior.
A review of Res #23's clinical record was conducted on 05/17/22 and documented the most recent annual assessment had been conducted on 02/21/21.
4. Res #127 was admitted on [DATE] and had diagnoses which included atrial fibrillation, heart failure, and dementia.
On 05/16/22, a review of Res #127's clinical record did not document an admission assessment had been conducted.
On 05/16/22 at 10:58 a.m., the DON stated a comprehensive admission assessment had not been completed for Res #127 or #128.
On 05/17/22 at 4:59 p.m.,, the DON stated she was behind on completing the residents comprehensive assessments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
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 ...
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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 to requiring limited assistance with ADLs.
The resident's medical record did not include a quarterly assessment which was due in February 2022.
On 05/12/22 at 9:20 a.m., the DON/MDS coordinator stated she was behind on MDS assessments and care plans because she had been working as charge nurse.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
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 reside...
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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 report documented the quarterly resident assessments had been received on 05/11/22. The transmittal report from CMS documented the assessments had been received late.
On 05/17/22 at 5:27 p.m., the DON reported the quarterly resident assessments for Res #21, 19, and #24, had been submitted to CMS late.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
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 fail...
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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, documented the facility was to administer Geodon (an antipsychotic medication) 80 mg capsule every twelve hours for a diagnosis of schizoaffective disorder.
A physician order, dated 06/01/20, documented the facility was to administer Depakote ER (an anticonvulsant medication) 250 mg every 12 hours for a diagnosis of dementia with behavioral disturbances.
A physician order, dated 10/22/20, documented the facility was to administer Neurontin (an anticonvulsant medication) 100 mg three times for a diagnosis of anxiety disorder.
Res #18's care plans, last reviewed on 06/22/21, documented the resident had the potential to be verbally aggressive related to disease process. The care plan documented Res #18 used psychotropic medications related to behavior management with a goal documented to be free of drug related complications.
A quarterly resident assessment, dated 01/29/22, documented the resident was intact in cognition and received antipsychotic and antidepressant medications for seven days of the seven day assessment period. The assessment documented a GDR was not attempted.
The consultant pharmacist MRR forms were reviewed from 04/28/21 through 03/20/22 and did not document any recommendation from the pharmacist to Res #18's physician to review the use of psychotropic medications for possible GDR. The April 2022 MRR reports were not available during the survey.
On 05/12/22 at 11:41 a.m., the DON reported the consultant pharmacist MRR's for April 2022 had not yet been provided to the facility. The DON stated they would call the pharmacist to fax the MRR reports over.
On 05/12/22 at 3:08 p.m., the DON and administrator reviewed the MRR policy and stated it did not document time frames for each step in the process. The DON was asked about GDR requests for Res #18. The DON stated the pharmacist no longer requests any reductions for Res #18 because he is schizophrenic.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected multiple residents
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 Residen...
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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 documentation of completed lab work.
On 05/16/22 at 3:55 p.m., LPN #1 stated the lab results for Res #126 were not able to be located.
On 05/16/22 at 4:01 p.m., the DON stated the lab the facility used had run out of lab supplies. The DON stated when the lab supplies became available the lab could resume collecting tests. She stated Res #126's lab requests had been overlooked as the resident was not on the April lab list.
2. Resident #127 had diagnoses which included dementia with behavioral disturbance, cerebral infarction, and heart failure.
A physician order, dated 03/22/22, documented the facility was to obtain a Depakote level, lipid panel, liver panel, and a digoxin level every three months
On 05/16/22 at 10:30 a.m., Res #127's clinical records were reviewed and documented lab tests were obtained on 03/25/22 which consisted of a lipid panel and a direct bilirubin test. The clinical record did not document a Depakote level or digoxin level had been obtained.
On 05/16/22 at 11:03 a.m., the DON stated lab orders were documented in a notebook for the month they were due and the notebook was kept at the nurse station. The DON reviewed the notebook for the month of March 2022 and stated she did not see where Res #127's labs had been documented in the notebook. The DON stated the Depakote and digoxin level had not been obtained.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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 ...
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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 was wearing gloves. [NAME] #1 changed gloves and then was observed to touch his face mask, wiped up sauce with a napkin, touched the trash can lid, and then changed gloves again, hand washing was not observed between glove changes.
On 05/12/22 at 3:36 p.m., cook #1 dropped trash on the floor, picked it up, removed one glove and threw it away, put on another glove and took the meatballs out of the oven. He did not perform and washing before he put on the glove. [NAME] #1 did not take the temperature of the meat balls before he placed them in the container on the steam table. [NAME] #1 was observed to open the trash can lid threw his trash away then touched his mask with gloved hand and returned to the stove and stirred the sauce and corn.
On 05/12/22 at 3:42 p.m., cook #1 removed the sauce from stove took it to the steam table and did not temp the sauce. At this time cook #1 was asked if he had tempted the meatballs or sauce. [NAME] #1 stated the meatballs were pre made meat balls and he didn't temp them. He stated he temps chicken. He was asked for the temperature logs. [NAME] #1 stated he did not know where the temp logs were.
On 05/16/22 at 12:03 p.m., cook #2 was asked what the holding temps were for the food on the steam table. [NAME] #2 stated should be 165. [NAME] #2 stated she temps the food before she puts it on steam table and before she serves the food. [NAME] #2 stated temp logs are normally on the refrigerator but they are not there.
On 05/16/22 at 12:07 p.m., cook #2 touched the trash can lid, removed her gloves, then touched a plate lid cover handing it to a staff member in the dining room. She then washed her hands before returning to steam table.
On 05/16/22 at 12:10 p.m., cook #2 stated she had not documented cooking or holding temp down for today.
On 05/16/22 at 12:11 p.m., the DM stated the cooks should be temping the food after cooking and then before serving the food. She stated maintenance should be cleaning the fan levers in the ceiling. DM stated kitchen staff should wash hands as soon as they go into the kitchen and they should wash their hands before new gloves are put on.
On 05/16/22 at 1:52 p.m., the DM stated she did not find any cooking temp just holding temp logs. She stated the cook did not check lunch temps today. The DM provided two temp logs at this time and they were reviewed. The holding temperature logs for 05/02/22 through 05/08/22 showed there were four evening shift meals which did not document any holding temps. The log dated 05/09/22 through 05/15/22 documented meat temps every day except for breakfast and dinner for Thursday 05/12/22. Multiple temps for vegetables and other items were missing on multiple days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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 o...
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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 for medications. She stated she did not understand how it cold be an infection control problem. At that time a roach was observed crawling on top of insulin cart then onto second shelf. The bottom shelf contained dirt and debris.
On 05/12/22 at 4:58 p.m., the DON was informed of the insulin cart going inside the residents rooms. She stated the nurse should have taken only one resident's insulin at a time in the room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
2. On 05/11/22 at 2:20 p.m., Res #13 complained of small black bugs in his bed and on the pillow. Res #13 stated the bugs caused itchy bites and did not know what kind of bugs they were. Res #13 indic...
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2. On 05/11/22 at 2:20 p.m., Res #13 complained of small black bugs in his bed and on the pillow. Res #13 stated the bugs caused itchy bites and did not know what kind of bugs they were. Res #13 indicated several red spots on his arms. At that time, Res #13's bed was observed and several spots of what appeared to be dried blood was on the sheets and two bed bugs were observed.
On 05/17/22 at 2:23 p.m., the administrator stated the facility had contracted with a professional pest control service that sprayed for pests regularly and utilized Diatomaceous Earth between treatments. The administrator stated the facility also spot treated resident rooms between professional treatments if notified of problems with bed bugs in a new area. The administrator was asked if they were aware of the bed bugs observed in a resident room on the east hall. The administrator stated they had not been told of any issues with pests on the east hall. The administrator was asked if they were aware of cockroaches in and on the insulin cart. The administrator stated cockroaches should not have been anywhere medications were stored or prepared.
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 observed on the curtain next to the bed. CNA #2 and #1 entered the room to strip the bedding. Blood was observed on the sheets. The curtains were also taken down at that time and multiple bed bugs both alive and dead were observed on the curtains. The mattress was observed to have a mattress cover on it and several live bed bugs were observed on the mattress cover. The CNAs who were cleaning the room were observed to spray the bed bugs with a bleach spray. The bed frame was observed to have bug droppings all over it.
On 05/11/12 at 1:56 p.m., Res #17 complained of bed bug bites. Two bites were observed on the resident's arm. Res #17 stated when he saw a bed bug he would kill it.
On 05/11/22 at 5:01 p.m., Res #23 stated there were bed bugs that had bitten him in his room. At that time, the DON reported the facility had treated the resident's skin but did not believe the condition was from bites. The DON stated they did not know what to do about the bed bugs as the facility had a professional pest control company to spray for bed bugs and had steamed cleaned the residents' belongings.
On 05/12/22 at 3:30 p.m., the administrator provided receipts from the pest control company for February, March, and April 2022. Zenoprox was one of the insecticides documented on the receipts.
On 05/12/22 at 4:46 p.m., an observation of insulin preparation for Res #78 was conducted. A cockroach was observed crawling on the top of the insulin cart then onto the second shelf. The bottom shelf of the insulin cart was observed to contain dirt and debris. LPN #1 was observed to knock the cockroach off the cart and stepped on it.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 1 harm violation(s), $60,140 in fines. Review inspection reports carefully.
- • 49 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $60,140 in fines. Extremely high, among the most fined facilities in Oklahoma. Major compliance failures.
- • Grade F (1/100). Below average facility with significant concerns.
Bottom line: Trust Score of 1/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Rainbow Terrace's CMS Rating?
CMS assigns RAINBOW TERRACE CARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Oklahoma, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Rainbow Terrace Staffed?
CMS rates RAINBOW TERRACE CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes.
What Have Inspectors Found at Rainbow Terrace?
State health inspectors documented 49 deficiencies at RAINBOW TERRACE CARE CENTER during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 46 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Rainbow Terrace?
RAINBOW TERRACE CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 60 certified beds and approximately 33 residents (about 55% occupancy), it is a smaller facility located in WELEETKA, Oklahoma.
How Does Rainbow Terrace Compare to Other Oklahoma Nursing Homes?
Compared to the 100 nursing homes in Oklahoma, RAINBOW TERRACE CARE CENTER's overall rating (1 stars) is below the state average of 2.6 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Rainbow Terrace?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Rainbow Terrace Safe?
Based on CMS inspection data, RAINBOW TERRACE CARE CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Oklahoma. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Rainbow Terrace Stick Around?
RAINBOW TERRACE CARE CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Rainbow Terrace Ever Fined?
RAINBOW TERRACE CARE CENTER has been fined $60,140 across 1 penalty action. This is above the Oklahoma average of $33,680. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Rainbow Terrace on Any Federal Watch List?
RAINBOW TERRACE CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.