Inspection Reports for
Laguna Rainbow Nursing Center

The complaint investigation found that staff held the resident's hands across her chest to prevent hitting during toileting despite combative behavior, resulting in bruising and a skin tear. The facility suspended involved CNAs pending investigation. The Administrator confirmed that rough handling or physical restraint during care is not acceptable.

The facility failed to ensure residents were free from abuse when staff inappropriately applied physical restraint to a resident during care, resulting in bruising and a skin tear. Staff held the resident's hands to prevent hitting, but continued care despite combative behavior, contrary to facility policy.

The complaint investigation revealed failure to submit a timely and thorough follow-up report regarding an alleged abuse incident involving a resident. The facility's Five Day Follow-Up Report was undated and there was no confirmation from the State Agency that the report was received as of the interview date.

The facility failed to complete and document a timely and thorough investigation of abuse allegations for one resident, and did not provide adequate orientation, training, and competency verification for nursing staff, including abuse, neglect, and exploitation training prior to providing direct resident care.

The complaint investigation found the facility failed to report the unexpected death of resident #1, did not conduct an internal investigation, and inaccurately documented the resident's discharge status. The complaint was substantiated based on interviews with the Assistant Director of Nursing, Administrator, and Medical Director.

The facility failed to report an unexpected death of a resident to the State Survey Agency, did not conduct an internal investigation or submit a reportable event, and inaccurately documented the resident's discharge status as home instead of deceased. These failures compromised regulatory compliance and the ability to track care outcomes.

The facility failed to secure medications properly, allowing unauthorized access to controlled substances, and failed to maintain the dishwashing machine at the required sanitizing temperature of 120°F, potentially exposing residents to harm.

The complaint investigation was substantiated with findings that resident #17 was sexually assaulted by another resident. The facility initiated an investigation, notified authorities, and took actions including one-to-one monitoring and discharge of the alleged perpetrator. Resident #17 experienced acute stress disorder and psychosocial harm.

The facility failed to prevent sexual abuse of a resident by another resident, resulting in actual harm and psychosocial distress. Additional deficiencies included failure to update care plans after falls, inadequate wound care for pressure ulcers, and failure to provide required dementia and abuse training to Certified Nurse Aides.

The facility was found deficient in multiple areas including failure to update care plans after resident falls, failure to assist residents in accessing vision services, inadequate pressure ulcer care, unsecured medication storage, poor infection prevention practices including lack of contact precautions and water management program, absence of a designated infection preventionist, failure to educate residents on immunizations, and insufficient dementia and abuse training for nurse aides.

The complaint investigation found that the facility did not notify the resident's POA or on-call provider about the injury within the required two-hour timeframe. The Director of Nursing confirmed the staff's failure to make timely notifications.

The facility failed to notify the POA and healthcare provider within two hours after staff found a resident with an injury of unknown origin. Notification was delayed until two days later, preventing timely decision-making and advocacy for the resident's care.

The facility had multiple deficiencies including failure to assess residents for self-administration of medication, inadequate safeguarding of protected health information, failure to prevent resident-to-resident abuse, incomplete care plans, use of unapproved medications, incomplete discharge summaries, insufficient behavioral health services, improper medication storage, food safety violations, infection control lapses, incomplete antibiotic stewardship, and malfunctioning resident call light systems.

The facility failed to update one of three resident care plans to reflect changes in the resident's condition and care preferences, including end-of-life and palliative care orders. This deficiency could result in unclear documentation of the resident's course of care and treatment options.

The investigation was complaint-driven, triggered by reports of a resident burn from hot liquid, catheter care concerns, food handling safety issues, and vaccination deficiencies. Substantiation is implied by the findings but not explicitly stated.

The facility was found deficient in multiple areas including failure to identify and mitigate hot liquid hazards resulting in a resident burn, improper catheter bag placement risking infection, unsafe food handling practices by staff, and failure to ensure residents received recommended pneumococcal vaccinations.