Laguna Rainbow Nursing Center

Inspectors wroteBased on observation and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions, when they failed to:Ensure staff served beverages to residents in a clean manner and without the staff members hands touching the rim of the cup. Ensure there are no expired cans in the kitchen. Ensure food and beverage items are stored appropriately and not left open to air. Ensure there is no accumulated residue on condiment containers in the kitchen. This deficient practice is likely to affect all 43 residents identified on the resident census list provided by the Administrator on 03/09/26. If food is not stored, prepared, and served under sanitary conditions, then residents are at an increased risk of contracting foodborne illness.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's Level 1 Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was reviewed for accuracy and completion for 4 (R #2, R #5, R #8 and R #31) of 4 (R #2, R #5, R #8 and R #31) residents reviewed. If the facility fails to review PASARR screenings for accuracy and completion, then residents with serious mental illness or intellectual disability may receive inappropriate placement and care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to properly secure and store medications located in the facility medication cart and medication storage room, when:The facility did not lock a medication cart (moveable equipment used for the storage, transport, and administration of medications) while staff were not present. The facility did not ensure the medication refrigerator temperatures were properly maintained within the appropriate temperature range (36 to 46 degrees Fahrenheit). If the facility fails to secure medication carts or properly store medications, residents may experience unauthorized access to medications and the risk of medications becoming unusable for administration, thereby not receiving the full therapeutic benefit of their medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident's medical records contained documentation regarding education, offering, or administration of the COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccination (treatment with a vaccine to produce immunity to a particular infections disease or pathogen) for 2 (R #4, and R #12) of 5 (R #4, R #6, R #12, R #18, and R #27) residents reviewed. This deficient practice is likely to result in residents not being provided information regarding opportunity for vaccination, and further result in increased risk of infection.

Inspectors wroteBased on record review and interview, the facility failed to ensure a psychotropic medication (medication used to treat mental health conditions) consent form was completed and signed by the resident or resident representative prior to medication administration for 1 (R #4) of 1 (R #4) resident reviewed for unnecessary psychotropic medications. If a resident and/or their representative are not informed of the risks and benefits of the medication, they may not be able to make an informed decision regarding treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #8) of 1 (R #8) resident reviewed, when:The facility staff failed update R #8's plan of care to include an accurate advanced directive code status (a patient's preferences regarding medical interventions in the event of a medical emergency, such as cardiac arrest). This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation and interview, the facility failed to ensure the outdoor trash bin was covered to minimize odors and prevent pests or rodents. If staff fail to keep outdoor trash bins closed, the environment may become unsanitary, increasing the risk of pest infestation and disease transmission to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 (R #1) of 1 (R #1) resident reviewed when facility staff inappropriately applied physical restraint during the provision of care. If the facility performs inappropriate use of physical restraint during resident care, then residents are at risk for physical injury and psychological harm, including fear or distress related to staff interactions.

Inspectors wroteBased on record review and interviews, the facility failed to ensure nurse aides were competent to perform their assigned duties when the facility did not provide adequate orientation and training for new and existing employees. This deficient practice is likely to result in staff not receiving the necessary training to meet the care needs of residents. A. Record review of the facility's policies revealed the facility did not have a formal policy or process in place for the onboarding, orientation, and training of new and existing staff. B. Record review of staff training and competency records for Certified Nurse Aid (CNA) #1, CNA #3, and Registered Nurse (RN) #1 revealed facility was unable to provide the records. C. On 08/14/25 at 1:32 pm, during an interview, the Assistant Director of Nursing (ADON) stated he oversaw training for CNAs. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that all staff received abuse, neglect, and exploitation training prior to providing direct resident care. This deficient practice has the potential to increase the risk for harm to residents due to a lack of knowledge and awareness regarding resident rights and the reporting of abuse.

Inspectors wroteBased on record review and interview, the facility failed to complete and document a timely and thorough investigation regarding allegations of abuse (knowingly causing physical or mental harm or failing to provide goods and services necessary to avoid physical or mental harm) for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for abuse and neglect allegations when staff failed to complete and submit a thorough follow-up report for an incident involving R #1. If facilities do not submit follow-up reports, then the State Agency (SA) cannot assure the residents are safe and free of abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an unexpected death to the State Survey Agency for 1 (R #1) of 1 (R #1) resident reviewed for clinical decline and death. The facility failed to initiate an internal investigation, submit a reportable event to the State Agency, and document clinical findings in the medical record following the resident's death. If the facility fails to report unexpected deaths, then the State Survey Agency cannot evaluate compliance with Federal regulations.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and complete documentation in the medical record for 1 (R #1) of 1 (R #1) resident reviewed for death and discharge status. The facility failed to document the resident's death in the progress notes and inaccurately listed the resident as discharged to home, rather than deceased . If the facility fails to maintain complete and accurate records, then care outcomes cannot be appropriately tracked, regulatory compliance is compromised, and opportunities for review or improvement may be missed.

Inspectors wroteBased on record review, observation, and interview, the facility failed to assure medications were secured and inaccessible to unauthorized staff. This deficient practice had the potential to affect all 33 residents identified on the facility census list provided by the Administrator on 04/22/25. Improperly stored medications could result in a resident, staff member, or visitor taking the medications not prescribed to them.

Inspectors wroteBased on record review, observation and interviews, the facility failed to sanitize dishes when staff did not maintain the dish washing machine at 120 degrees (°) Fahrenheit (F), per manufacturer's instructions. This deficient practice was likely to affect all 33 residents of the facility. If the facility fails to ensure the dish machine reached the appropriate temperature, then residents could potentially be exposed to foodborne illnesses (illnesses caused by food contaminated with bacteria, viruses, parasites, or toxins.)

Inspectors wroteBased on record review and interview, the facility failed to prevent resident to resident sexual abuse for 1 (R #17) of 3 (R #5, #17 and #33) residents reviewed for abuse. This deficient practice likely resulted in psychosocial harm and distress for R #17, as evidence by the resident to become more withdrawn and isolated, experience anxiety and fear, and weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Ensure staff followed contact precautions (used for individuals with infections that can spread through direct or indirect contact with the patient or their environment) before contact with a resident and his environment for 1 (R #13) of 1(R #13) residents. This practice could likely lead to an increased risk of transmission of the bacteria to other patients and healthcare workers, potentially causing more infections due to direct contact with contaminated surfaces or the infected patient, which could result in serious complications like sepsis (presence of bacteria and infectious organisms in the blood stream) or even death if left untreated. 2. Demonstrate its measures to minimize the risk of Legionella (a type of bacteria that can cause legionellosis; [...]

Inspectors wroteBased on interviews and record review, the facility failed to designate one or more individuals as the Infection Preventionist (IP) who was responsible to assess, develop, implement, monitor, and manage the infection prevention and control program (IPCP; a set of practices and procedures that aim to reduce the spread of infections in healthcare facilities and other settings). This practice could likely cause a lack of dedicated oversight and implementation of proper infection control practices across the facility and lead to potential resident harm and a greater risk of outbreaks.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required dementia and abuse training for 12 (CNAs #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12) of 19 (CNAs #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) CNAs reviewed for dementia and abuse training. This deficient practice could likely result in the nurse aides not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on interviews, and record review, the facility failed to assist a resident in gaining access to vision services when staff failed to make appointments or arrange for transportation for 1 (R #30) of 1 (R #30) residents. This practice could likely lead to an increase in the risk of missing early signs of serious eye diseases like glaucoma (a group of eye conditions that can cause blindness) and macular degeneration (a medical condition which usually affects older adults and results in a loss of vision in the center of the visual field because of damage to the retina), which often have no noticeable symptoms in their early stages, potentially leading to significant vision loss or blindness if left untreated. Additionally, it could likely lead to missing a resident's prescription needs, causing eye strain and difficulties with daily activities.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #13) of 1 (R #13) resident reviewed for pressure ulcers (a wound caused by prolonged pressure occurring in bony areas of the body) received the necessary treatment and services to promote healing and prevent new ulcers from developing when staff failed to perform wound care for multiple days. This deficient practice likely worsened the wound for R #13, exposing bone and osteomyelitis (bone infection).

Inspectors wroteBased on observation and staff interview, the facility failed to ensure staff secured the medications inside the medication room and made them inaccessible to unauthorized staff and residents. This practice could likely give access to unauthorized staff, residents, and visitors, and could lead to medication misuse.

Inspectors wroteBased on interviews and record review, the facility failed to ensure nurses educated a resident or a resident's representative on the benefits and potential side effects of the pneumococcal immunization (a shot that helps protect you from serious bacterial infections caused by pneumococcal bacteria) before nurses offered the immunization for 1 (R #7) of 1 (R #7) residents. This practice could likely lead to improper decision making by R #7's legal guardian due to inadequate discussion on the risks and benefits of the immunization.

Inspectors wroteBased on record review, the facility failed to ensure staff revised the care plan for 1 (R #15) of 1 (R #15) residents reviewed when staff failed to update care plan after falls. This deficient practice could likely result in staff being updated and implementing the needs and treatments of resident.

Inspectors wroteBased on record review and interview, the facility failed to notify the Power of Attorney (POA; health care power of attorney grants, in writing, a particular agent the power to make healthcare decisions on another's behalf) and health care provider of 1 (R #1) of 1 (R #1) resident reviewed when staff found R#1 with a injury of unknown origin and did not notify the POA and the facility provider within two hours. If the facility is not notifying the resident's POA or provider when the resident has a change of condition, then the POA and provider are unable to make decisions related to treatment and advocate for the resident's care.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Discard fresh produce that was older than seven (7) days; 2. Provide a splash guard for items that are stored on the bottom shelf of a wire rack. This deficient practice has the potential to affect all 42 residents listed on the census that was provided by the facility on 09/25/23. This deficient practice could likely lead to a foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food and equipment are not being stored properly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection prevention measures by: 1. Propping open the door open from the dirty utility to the clean utility. 2. Having a fan on in the dirty utility room circulating air around where dirty linen was kept. 3. Staff failing to wear Personal Protective Equipment (PPE) when sorting through dirty linen. Transmission Based Precautions (TBCP-Wear gloves, gown, eye protection, and apron when in contact with residents' dirty linen) These deficient practices could likely result in residents being exposed to or developing infections they may otherwise have avoided.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (The effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance). This deficient practice has the potential to affect any of the 42 residents identified on the census provided by the Executive Director (ED) on 09/25/23, and who might be placed on antibiotics, which could result in the inappropriate use of antibiotics and that can lead to resistance of a multi-drug resistant organism.

Inspectors wroteBased on observation and interview, the facility failed to safeguard (secure or protect) clinical record information by leaving protected health information (PHI; personal identifying information) unattended. This deficient practice has the potential to affect all residents residing on Hall B (residents were identified by the Resident Census List provided by the Administrator on 09/25/23). If resident's clinical information is not adequately safeguarded, resident's PHI is likely to be accessed (obtained or examined) by unauthorized (not having permission or approval) residents, visitors, and/or staff.

Inspectors wroteBased on record review and interview, the facility failed to ensure 3 (R #25, #30 and #38) of 3 (R #25, #30 and #38) residents reviewed for behavioral health concerns received necessary behavioral health services and monitoring to meet the resident's need by: 1. Not providing counseling services/referral as ordered for R #38 and R #30. 2. Staff being inconsistent of identifying what is considered behaviors versus what is considered resident choice/self determination. This deficient practice could potentially cause poor communication and monitoring by staff, creating issues between the residents who are involved in relationships.

Inspectors wroteBased on observation, interview and record review the facility failed to: 1. Properly store medications in a medication cart; 2. Lock treatment carts when they were unattended. These deficient practices have the likelihood to result in all 16 residents in A hall, that were identified on the census list provided by the administrator on 09/25/23, allow access to discontinued medications that could be accidentally administered, allow residents treatments and treatment medications to be accessed by unauthorized (not having permission or approval) staff or residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the resident call light system was in complete working order as evidenced by hallway indicator lights not activating for 5 (R #4, R #42, R# 38, R #26 and R #16) of 15 (R #4, R #42, R #16, R #12, R #28, R #19, R #33, R #34, R #38, R #30, R #35, R #26, R #16, R #13, and R #9) resident call lights tested. This deficient practice could likely lead to residents being unable to indicate the need for help when in bed or in the restroom.

Inspectors wroteBased on observation and record review, the facility failed to have the Interdisciplinary team (IDT) (Consists of a team of professionals of various roles within the facility who review and determine resident needs and abilities) determine if residents could self-administer medication for 1 R #17) of 1 (R #17) residents viewed for treating a fungus infection. If the facility is not assessing the residents to determine if a resident is capable of self-administering medications then this deficient practice is likely to result in residents self-administering medications inappropriately and or incorrectly, causing harm.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident-to-resident abuse/neglect for 1 (R #30) of 3 (R #25, 30 and 38) residents reviewed for abuse/neglect. This deficient practice could likely cause physical and emotional harm to the resident when staff were unable to protect a resident from another resident physically assaulting her.

Inspectors wroteBased on record review and interview, the facility failed to update a care plan for 1 (R #41) of 3 (R #'s 21, 31, and 41) care plans reviewed for care plan accuracy. This deficient practice could likely result in staff not being aware of resident care needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to have physician orders for 1 (R #17) of 1 (R #17) resident by allowing the patient and staff to apply absorbase moisturizing cream to his coccyx without physician orders. This deficient practice could likely result in allowing residents to use over the counter medication and could cause residents to suffer adverse (unintended) reactions to medications that are not appropriate for the resident.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive discharge summary that would include a recapitulation of the resident's stay, for 1 (R #46) of 1 (R #46) residents reviewed for the discharge process. This deficient practice could likely result in an intermittent continuation of care due to the lack of information.