A list of the most recent deficiencies for Rainbow Terrace Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-12 | 2023-11-02 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-09-12 | 2023-10-31 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-12 | 2023-10-20 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-12 | 2023-10-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-12 | 2023-10-16 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-09-12 | 2023-10-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-12 | 2023-10-16 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-09-12 | 2023-10-16 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-09-12 | 2023-10-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-12 | 2023-10-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-12 | 2023-09-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-12 | 2023-09-22 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-09-12 | 2023-09-22 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-09-12 | 2023-09-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-12 | 2023-09-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-13 | 2023-08-15 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-06-13 | 2023-08-15 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-06-13 | 2023-08-15 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-06-13 | 2023-08-15 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-13 | 2023-08-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-13 | 2023-08-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-13 | 2023-08-15 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-13 | 2023-08-15 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-13 | 2023-08-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-13 | 2023-08-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-13 | 2023-07-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-13 | 2023-07-25 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-06-13 | 2023-07-25 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-13 | 2023-07-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-13 | 2023-07-25 | Y |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2023-06-13 | 2023-07-25 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-13 | 2023-07-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-06 | 2022-08-01 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-05-17 | 2022-07-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-05-17 | 2022-07-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-05-17 | 2022-07-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-05-17 | 2022-07-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-17 | 2022-07-01 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-05-17 | 2022-07-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-17 | 2022-07-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-17 | 2022-07-01 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-05-17 | 2022-07-01 | N |
| Provide or obtain dental services for each resident. | Health | 2022-05-17 | 2022-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-17 | 2022-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-17 | 2022-07-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-12 | 2022-07-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-12 | 2022-07-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-12 | 2022-07-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-12 | 2022-07-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-05-12 | 2022-07-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-12 | 2022-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-15 | 2021-10-26 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-09-15 | 2021-10-26 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-09-15 | 2021-10-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-15 | 2021-10-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-15 | 2021-10-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-15 | 2021-10-26 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-09-15 | 2021-10-26 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-04 | 2019-10-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-04 | 2019-10-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-09 | 2019-10-28 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-09-09 | 2019-10-28 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-09 | 2019-10-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-09 | 2019-10-28 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-09-09 | 2019-10-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-09-09 | 2019-10-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-09 | 2019-10-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-09-09 | 2019-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-09 | 2019-10-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-09 | 2019-10-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-09 | 2019-10-28 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-09-09 | 2019-10-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-09 | 2019-10-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-09 | 2019-10-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-09-09 | 2019-10-28 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-09-09 | 2019-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-09 | 2019-10-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-09-04 | 2019-09-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-04 | 2019-09-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-04 | 2019-09-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-10-10 | 2018-12-14 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-10-10 | 2018-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-10 | 2018-12-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-10 | 2018-12-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-10-10 | 2018-12-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-10 | 2018-12-04 | N |
| Have an externally vented heating system. | Fire Safety | 2018-10-10 | 2018-12-01 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-10-10 | 2018-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-10 | 2018-11-05 | N |
