Every finding on record at Rainbow Hospice Care

Based on record review and interview, the facility did not inspect the kitchen range hood equipment in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.2.5 & 9.2.3; and NFPA 96 (2011 edition) Sections 11.4, 11.6, 11.6.1 & 11.6.13. These deficient practices could affect all residents an undetermined number of staff and visitors. --- Findings include:On 07/15/2025 at 9:40 am, review of inspection records for the kitchen-hood exhaust and fire suppression system over the past 18 months revealed that the facility was missing a semi- annual inspection for 2025.  The prior two semi-annual inspections were conducted on 11/20/24 and 5/8/24 by Ahern. This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff E.

Based on observation and interview, the facility did not maintain an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems 2010 edition as required in NFPA 101: Life Safety Code, 2012 edition sections 9.7, 9.7.1.1(1), 19.3.5.1; NFPA 13 (2010 edition) Sections 6.2.9.1 & 6.2.9.7. This deficient practice could affect all residents and an undetermined number of staff and visitors. --- Findings include: On 07/15/2025 at 12:05 pm, observation in the fire sprinkler riser room revealed two spare sprinkler head boxes located near the sprinkler supply riser did not include a list of sprinkler heads installed at the facility. This condition was confirmed at the time of discovery by Staff E.

Based on observation and staff interview, the facility failed to properly maintain electrical devices in accordance with NFPA 101, 2012 edition, Sections 19.5.1.1, 19.3.5.1, 19.3.5.4, 9.1.2, and 9.7.1.1; NFPA 13, 2010 edition, Sections 6.1.1 and 7.2.6.2; as well as NFPA 70, 2011 edition, Sections 110.13(A). This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. --- Findings include: On 07/15/2025 at 12:00 pm, observation in the basement sprinkler room also known as water closet room revealed air compressor used for the dry fire sprinkler system did not have a reliable power source able to restore normal air pressure to the system within 30 minutes. The compressor was connected a standard wall switch in 4”x 4” metal box without any safeguards for the switch.  These deficient practices were confirmed by Staff E at the time of discovery.

Based on record review and interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 (2012 edition) Sections 4.7.1, 4.7.2, 4.7.4, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6.  This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. --- Findings include:   On 07/15/2025 at 10:23 am, review of the fire drill records for the last twelve months revealed that the fire drills were not conducted at varied times. The facility operates daily with two 12-hour shifts (7 am to 7 pm day shift and 7 pm to 7 am night shift). The facility performed fire drills during the day shift, second quarter on 6/26/25 at 2:38 pm and on third quarter, 8/05/2024 at 3:15 pm. The facility also performed fire drills during the night shift on second quarter, 6/26/2025 at 3:00 am and on third quarter, 9/30/2024 at 3:00 am. This condition was confirmed at the time of discovery by a concurrent interview with Staff A, Staff B and Staff E.

Based on record review and interview, the facility failed to inspect fire/smoke door assemblies at least annually, with written records of inspection and testing in accordance with NFPA 101(2012 edition), sections 19.2.2.2.1, 19.7.6, 4.6.12, 7.2.1.15, 8.3.3. This deficient practice could affect all residents and an undetermined number of staff and visitors. --- Findings include: On 07/15/2025 at 9:30 am, it was noted during record review that the facility lacked complete documentation of which fire/smoke door assemblies had been inspected or tested in the last year.  Facility lacked a list of fire/smoke door assemblies that had been tested and their location and through interview facility lacked inspection of boiler room door and the oxygen room door. This deficient practice was confirmed by Staff E at the time of discovery.

Based on record review, observation and interview, the facility did not complete maintenance and testing of the emergency generator and transfer switches accordance with the requirements of NFPA 101, 2012 edition, Sections 19.5.1 and 9.1.3; as well as NFPA 110, 2010 edition, Sections 5.3.1, 8.3.4 & 8.3.8, NFPA 99, 2012 edition, 6.5.4.1.1.2, 6.4.4.1.1, This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. --- Findings include:1.   On 07/15/2025 at 9:59 am, record review and interview of the annual generator tests revealed that no annual fuel oil test was performed with results recorded in accordance with fuel oil requirements of ASTM D975 in the past 12 months.  Prior fuel test was on 03/08/2024.2.   On 07/15/2025 at 11:36 am, observation indicated that no heat was being provided by the generator's jacket water heater. These deficient conditions were confirmed at the time of discovery by concurrent interview with Staff E.

Based on observations and staff interview, the facility failed to properly maintain electrical devices in accordance with NFPA 101 (2012 edition), Sections 19.5.1.1 and 9.1.2, and NFPA 70 (2011 edition) Sections 400.8, 590.2(B) and 300.4. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. --- Findings include: On 07/15/2025 at 11:50 am, observation in the laundry room located on the first floor revealed that the electrical power for the soap and chemical pumps for the washing machine was supplied by plugging in an approximately 50-foot-long white extension cord that was run up an opposite wall to the top of a ventilation duct where it was coiled.  It then ran across an opening in the wall along the ceiling and down the wall to the washer.  The cord entered the electrical box through a connector that was designed for flexible metal conduit and the opening in the connector was larger than the cord's diameter. These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff E.

Based on record review and interview, the agency Registered Nurse (RN) failed to assess wound status per agency policy in 1 of 1 patient (Patient #14) in a total of 19 records reviewed. --- Findings Include:Review of procedure #CP.M165 “Managing Pressure Ulcers” dated 7/23/2024 revealed in part “3. Monitor and assess the ulcer with all comprehensive assessments.” Further review revealed, “11. Document treatment, assessment for signs and symptoms of infection, dimensions of ulcer including length, width, and depth, the presence of undermining and/or tunneling.”    Review of agency policy titled "Interdisciplinary Team (IDT) Meeting" dated 03/01/2023 revealed "Procedure: 4. The focus of IDT meeting is to review the patient's plan of care and revise it as needed, based on the updated comprehensive assessments."  Record review for Patient #14 revealed Patient #14 resides at home and admitted to hospice with start of care 05/29/2025. Review of the Plan of Care (POC) Report revealed "Primary diagnosis of “Neoplasm uncertain behavior of trachea, bronchus and lung. Plan of care Problem (starting 06/03/2025): Symptom management need due to skin integrity: Goal: For patient will maintain skin integrity throughout the end of life, ongoing. Intervention: RN to assess coccyx at each visit."Record review of Patient #14's RN Comprehensive Assessment visit note documentation revealed on 06/03/2025: “Skin: Coccyx red. See wound/ulcer assessment.”  Review of the RN Comprehensive Assessment visit notes dated 06/10/2025, 06/17/2025, 06/24/2025 and 07/08/2025 revealed “Skin: See wound/ulcer assessment. See wound care,” and corresponding “Wound forms” dated 06/03/2025, 06/10/2025, 06/17/2025 and 06/24/2025 revealed the RN Comprehensive assessments failed to include an assessment and measurement of the coccyx pressure area per agency policy.Record review of Interdisciplinary Group (IDG) Notes and update of the RN comprehensive assessment for Patient #14 for IDG related to the coccyx pressure area revealed: 06/16/2025: “Small pressure area to coccyx.” 07/01/2025: “RN education to Healthcare Power of Attorney (HCPOA) and daughter on wound care.” Neither note for the IDG meeting updated the findings of the RN comprehensive assessment of the coccyx pressure area.Per email communication with Chief Executive Officer (CEO) C on 07/15/2025 at 3:42 PM, "I agree we should have documented more thoroughly on these patients’ wounds and expected outcome."

Based on record review and interview, the agency staff failed to maintain professional management responsibility of hospice services for wound management in 2 of 2 patients with wounds residing in a care facility (Patient #4 and #15) out of a total of 19 patient records reviewed. --- Findings Include:Review of procedure #CP.M165 “Managing Pressure Ulcers” dated 7/23/2024 revealed in part “3. Monitor and assess the ulcer with all comprehensive assessments.” Further review revealed, “11. Document treatment, assessment for signs and symptoms of infection, dimensions of ulcer including length, width, and depth, the presence of undermining and/or tunneling.”    Review of Patient #4’s medical record revealed Patient #4 was admitted to hospice service on 1/17/2025 with a primary diagnosis of chronic diastolic (congestive) heart failure. Secondary diagnoses included unspecified dementia. Patient #4 resided in a Skilled nursing facility (SNF).Review of Patient #4’s recertification period of 5/17/2025 to 7/15/2025 “Plan of Care” revealed skin integrity intervention of ‘Hospice Nurse’ to assess skin breakdown with comprehensive assessment, wound care and as needed. The Plan of Care revealed that Patient #4 had a pressure ulcer on coccyx and included the ordered wound care. The Plan of Care also revealed that Patient #4 required maximum assistance with all activities of daily life and was unable to reposition self.Review of Patient #4’s Comprehensive Assessments during the recertification period revealed:5/19/2025 “Skin: decubitus/wound/ulcer.” There was no documentation of a wound assessment being completed.5/27/2025 “Skin: see wound/ulcer assessment.” There was no documentation of a wound assessment being completed.6/2/2025: There was no documentation of a wound being present.6/9/2025 “Skin: wound care managed by facility per their policy.” There was no documentation of a wound assessment being completed.6/16/2025 “Skin: decubitus/wound/ulcer.” There was no documentation of a wound assessment being completed.6/23/2025: There was no documentation of a wound assessment being completed.6/30/2025: “Skin: decubitus/wound/ulcer. [Patient #4’s] wounds are not improving. Wound care staff reporting that they are becoming more necrotic.” There was no documentation of a wound assessment being completed.7/7/2025: “Skin: decubitus/wound/ulcer. Report from [floor nurse] is that [Patient #4’s] wounds are getting worse, especially one on his/her knee.” There was no documentation of a wound assessment being completed.7/14/2025: “Skin: coccyx 4.4cm (centimeters) by 3.3 cm by 1.2 cm. Right outer knee 2cm by 3cm by 0.6 cm.”  There was no documentation of a wound assessment being completed.Review of Patient #15’s medical record revealed Patient #15 was admitted to hospice services on 5/06/2025 with a primary diagnosis of Cerebrovascular Disease with secondary condition of local infection of the skin and subcutaneous tissue and resided in a SNF.Review of Patient #15’s initial certification period of 5/06/2025 to 7/15/2025 “Plan of Care” revealed skin integrity intervention of ‘Hospice Nurse’ to assess skin breakdown. The Plan of Care revealed that Patient #15 had a Stage 2 pressure ulcer to coccyx on admission.Record review of Patient #15’s “RN Comprehensive Assessment” visit notes during initial certification period dated 05/07/2025, 05/12/2025, 05/16/2025, 05/19/2025, 05/22/2025, 05/28/2025, 06/03/2025, 06/16/2025 and 06/25/2025 revealed, “Skin/Integumentary: See wound assessment/wound form for documentation” with no further documentation. Review of corresponding “Wound Form” for comprehensive assessment dates revealed “Comment: Facility managing wound on coccyx.” There is no documentation of a wound status and assessment being completed at any visit. During an interview on 07/15/2025 at 12:15 PM, Senior Director of Hospice B stated, "We would expect our nurses to be documenting the measurements and the wound status and be able to see in the plan of care for those directions.”

Based on observation, record review and interview, the agency failed to demonstrate compliance with the physical environment and life safety from fire requirements for 1 of 1 inpatient facility [1225 Remmel Drive Watertown, WI 53094] reviewed. --- Findings include:See K tags for deficiencies cited.

A Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 08/01/2022. Based on observation, staff interviews, and review of maintenance records, Rainbow Hospice Care did NOT construct, install and maintain the building systems to ensure physical environment to inpatients. 42 CFR 418.110(c) Condition of Participation: Physical Environment was NOT MET Findings include: The facility was found to contain the following deficiencies: K345 Fire Alarm System - Testing and Maintenance K353 Sprinkler System - Maintenance and Testing K712 Fire Drills K918 Electrical Systems - Essential Electrical Systems Maintenance and Testing K923 Gas Equipment - Cylinder and Container Storage Refer to the full description at the cited K tags. The cumulative effect of the environmental deficiencies results in the Hospice's inability to ensure a safe environment for inpatients, visitors, and staff was not maintained in accordance with the Life Safety Code (NFPA 101-2012).

A Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 08/01/2022. Based on observation, staff interviews, and review of maintenance records, Rainbow Hospice Care did NOT construct, install and maintain the building systems to ensure fire protection for inpatients. 42 CFR 418.110(d) Standard: Life Safety Fire Protection was NOT MET Findings include: The facility was found to contain the following deficiencies: K345 Fire Alarm System - Testing and Maintenance K353 Sprinkler System - Maintenance and Testing K712 Fire Drills K918 Electrical Systems - Essential Electrical Systems Maintenance and Testing K923 Gas Equipment - Cylinder and Container Storage Refer to the full description at the cited K tags. The cumulative effect of the environmental deficiencies results in the Hospice's inability to ensure fire protection for inpatients, visitors, and staff was not maintained in accordance with the Life Safety Code (NFPA 101-2012).

Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.4.1, 9.6.1.3, 9.6.1.5, 9.6.2.10.1.1, and 9.7.2.1; as well as NFPA 72, 2010 edition, Sections 14.3.1 and 14.4.5. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 08/01/2022 at 1:38 PM, record review of fire alarm inspection and testing documents over the past 24 months revealed that J.F. Ahern Company conducted the last smoke detector sensitivity testing of the fire alarm system on 01/25/2022. The testing on this date did not include the current reading of each smoke detector. Previous testing on 07/15/2020 also did not include the current reading of each smoke detector. Last testing to include both the acceptable range and the actual reading of each smoke detector occurred on 07/31/2017. This deficient practice was confirmed by Staff A, C, and D at the time of discovery.

Based on observation and interview, the facility did not maintain the automatic sprinkler system in accordance with NFPA 101, 2012 edition, Sections 19.3.5.1, 19.3.5.7, 9.7.5, 9.7.1.1; NFPA 25, 2011 edition, Section 5.2.1.2; NFPA 13, 2010 edition, Sections 8.1.1, 8.5.6, 8.6.5.3, and 8.6.6.1. These deficient practices could affect 2 residents and an undetermined number of staff and visitors. Findings include: 1. On 08/01/2022 at 3:22 PM observation in the Patient Room 116 entry cabinet closet revealed that (4) bed linens were stored 4 inches below a pendant sprinkler head. 2. On 08/01/2022 at 4:02 PM, observation in the Closet within Office 107 revealed that (2) 8 inch tall vases and (2) 7 inch tall, holiday decorative objects were stored 8 inches below a pendant sprinkler head. 3. On 08/01/2022 at 3:29 PM observation in the Patient Room 115 entry cabinet closet revealed that (3) bed linens were stored 6 inches below a pendant sprinkler head. These deficient practices were confirmed by Staff A, C, and D at the time of discovery.

Based on record review and interview, the facility did not conduct fire drills at unexpected times to ensure that staff are familiar with fire response procedures so that the staff's ability to respond to fire emergencies is adequately tested as required by NFPA 101, 2012 edition, 19.7.1, 19.7.1.6, 4.7.1, 4.7.2, 4.7.4, and 4.7.6. This deficient practice could affect all the residents and an undetermined number of staff and visitors. Findings include: On 08/01/22 at 1:51 PM, a review of fire drill reports for the last twelve months revealed that fire drills were conducted in a predictable pattern, so they were not always at unexpected times. During the twelve hour AM shift, four of four AM shift fire drills were conducted between 5:10 AM and 5:45 AM. During the twelve hour PM shift, two of four PM shift fire drills were conducted at 1:45 PM and 1:16 PM. Fire drills for the AM shifts and PM shifts were conducted at the following dates and times in the past twelve months. AM Shift Quarter Date Time 4th 12/28/2021 5:10 AM 1st 03/30/2022 5:30 AM 2nd 06/20/2022 5:45 AM 3rd 07/27/202 5:30 AM PM Shift 4th 12/26/2021 09:33 PM 1st 03/28/2022 01:45 PM 2nd 06/30/2022 08:40 PM 3rd 07/27/2022 01:16 PM This deficient practice was confirmed by Staff A, C and D at the time of discovery.

Based on record review and interview, the facility did not complete maintenance and testing of the generator and transfer switches in accordance with requirements of NFPA 101, 2012 edition, Sections 19.5.1 and 9.1.3, as well as NFPA 110, 2010 edition, Section 8.3.4 and 8.4.9. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 08/01/2022 at 1:15 PM, record review revealed no evidence that the 80 kW, exterior mounted, diesel emergency generator had been exercised with load once every 36 months for at least 4 hours of continuous, rated load with at least one test transfer switch operation. The deficient practice was confirmed at the time of discovery by Staff C and D.

Based on observation and interview, the facility did not store oxygen cylinders in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.2.4 and 8.7, as well as NFPA 99, 2012 edition, Sections 11.3.2, 5.1.3.3.2(4), and 5.1.3.3.2(10). These deficient practices could affect 4 residents, as well as an undetermined number of staff and visitors. Findings include: On 08/01/2022 at 4:12 PM, observation in the Oxygen Room on the Lower Level revealed (11) Type H Oxygen cylinders, (3) 45 L Liquid Oxygen Tanks, and (1) Type "E" oxygen cylinders stored within the room, along with vinyl wall base that were not constructed of non-combustible or limited combustible material. The deficient practice was confirmed at the time of discovery by Staff A, C, and D.