Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rainbow Rehab And Healthcare during CMS and state inspections, most recent first.
A resident who was cognitively intact, full code, and dependent on staff for incontinence care developed an acute change in condition with lethargy, speech changes, and decreased responsiveness. Staff did not complete a timely nursing assessment, obtain updated VS, notify the MD and family right away, or transfer the resident promptly; the resident was later diagnosed with an acute CVA and carotid stenosis. Records also showed missed/limited incontinent care, and hospital findings included sperm in the urine plus vaginal and thigh trauma.
A resident with full code status and an acute change in condition became nonverbal and lethargic, but staff did not complete a timely assessment, document the change, or notify the provider immediately. 911 was not called right away, and the resident was transferred to the ER hours later by ambulance. EMS identified a bruise on the resident’s cheek that facility staff had not documented, and the MD confirmed the transfer should have been emergent.
A resident with HTN, a pelvic fracture, OA, and overactive bladder developed decreased consciousness, decreased mobility, and lethargy, but the DNP and legal representative were not notified when the change first occurred. Staff later documented the change and arranged transfer to the ER, and interviews confirmed the DNP was notified only after 3 PM, while the RP was notified before transfer.
Failure to Document and Process Missing-Item Grievance: A resident with hemiplegia and hemiparesis and intact cognition was documented as missing a light blue shirt, but no grievance or concern was recorded in the facility log. Interviews showed the SSD, BOM, and Administrator described a grievance/reimbursement process for missing items, yet no grievance, reimbursement, or documentation of discussion was found for the resident's missing property.
A resident with an indwelling suprapubic catheter, severe cognitive impairment, and diagnoses including neurogenic bladder and CKD received improper catheter care when a CNA cleaned the catheter site without stabilizing the tubing and tugged on it during wiping. Facility policy and the catheter care skills checklist required the catheter to be secured and stabilized during care, and the DON stated staff were expected to follow the checklist.
Significant medication error involving IV ABT: a resident with a stage 4 sacral pressure ulcer and osteomyelitis had ertapenem ordered for a wound infection, but the MAR showed four missed doses after the order was entered with the wrong stop date. RN entered the order without verifying it against the hospital discharge instructions, and the DON confirmed the resident missed doses because the antibiotic was discontinued early.
Failure to Respond Timely to Acute Change in Condition and Provide Needed Care
Penalty
Summary
The facility failed to protect a cognitively intact, full-code resident from neglect when the resident developed an acute change in condition and the facility did not respond with timely assessment, notification, or transfer. The resident was found with lethargy, changes in speech, gurgling respirations, and later became unresponsive to verbal and tactile stimulation. Although the change in condition was noted in the morning, the record showed no nursing assessment, vital signs, or neurological assessment until about 4 hours later, and the physician and family were not notified at the time the change was first observed. The resident had a history of bladder and bowel incontinence, impaired mobility, and moisture associated skin damage to the right gluteus. The care plan called for toileting assistance, peri-care after each incontinent episode, barrier cream, and turning and repositioning. The record showed the resident was not provided incontinent care every 2 hours or as needed; on the day of the event, incontinent care was documented only twice before the resident left the facility. Staff interviews also indicated the resident was alert and oriented earlier in the day, then became difficult to arouse and different from baseline later that morning. The resident was transferred to the emergency room several hours after the change in condition and was diagnosed with an acute CVA and carotid artery stenosis. Hospital records later showed sperm in the urine, and a forensic exam identified bruising on the inner thigh and a tear on the lower vagina. Interviews with facility and hospital staff confirmed the delayed response to the resident's altered mental status, the lack of timely physician notification, and the absence of current assessment data on the transfer form. The facility was cited for failure to use its resources effectively to maintain the resident's well-being and to ensure the environment was free of neglect.
Delayed Assessment and Emergency Transfer During Acute Change in Condition
Penalty
Summary
The facility failed to provide timely assessment, notification, and emergency transfer for a resident who had an acute change in condition and altered mental status. The resident was cognitively intact on admission, had full code status, and was admitted for rehabilitation after hospitalization for hypertension, a right pubic fracture, osteoarthritis, and overactive bladder. On the morning of the event, staff observed that the resident became less talkative and then nonverbal, with a dazed appearance and altered mental status. Staff interviews showed that the change in condition was recognized, but the resident was not assessed with a head-to-toe evaluation at the time the change was identified, and the physician or NP was not notified immediately. The resident was not transferred to the hospital until approximately 5 hours after the change in condition was first noted. Staff interviews confirmed that 911 was not called immediately and that an ambulance service was used instead. The licensed nurse who saw the resident later stated she did not complete a full assessment and used earlier vital signs rather than obtaining a new assessment. The unit manager also confirmed she did not assess or document the resident’s change in condition and stated she should have called 911. The medical director confirmed that the change in condition and nursing assessments should have been accurately performed and documented, that the physician and NP should have been notified immediately, and that 911 should have been used for the transfer. During the transfer to the hospital, EMS personnel identified a contusion to the resident’s right cheek that facility staff had not documented or recognized. The facility administrator and regional clinical leadership stated the bruise was not known to them until several days after the transfer and acknowledged that if the bruise had been present it should have been documented. The hospital record showed the resident arrived with bruising to the right side of the face after a fall, and the survey findings concluded that the facility failed to provide care and services in accordance with professional standards of practice for timely assessment and emergency transfer during the resident’s acute change in condition.
Failure to Notify Physician and Representative of Change in Condition
Penalty
Summary
The facility failed to notify the DNP and the resident’s legal representative of a change in condition that was identified on 7/10/2026 at approximately 10:56 AM for Resident #1. Facility policy titled, Notification of Changes, required prompt notification of the resident, consultation with the resident’s physician, and notification of the resident’s representative when there was a significant change in physical, mental, or psychological condition, including deterioration in health or clinical complications. The facility’s Transfer and Discharge policy also required notification of the resident and/or resident representatives for emergency transfers or discharges initiated for medical reasons. Resident #1 was admitted with diagnoses including hypertension, a pelvic fracture, osteoarthritis, and overactive bladder. The skilled daily note documented that the resident experienced decreased consciousness, decreased mobility, and lethargy beginning at approximately 10:56 AM, with vital signs taken at that time, but the DNP and RP were not notified when the change first occurred. A later nurses’ note documented that an order was received to send the resident to the ER. The RP stated he was notified at about 3:30 PM before transfer, and the DNP confirmed she was notified after 3:00 PM but should have been notified when the change first occurred. CNA B, COTA E, and LPN F each described the resident as different, hard to awaken, or not assessed when the change occurred, and LPN F confirmed she did not notify the DNP or family when the change began.
Failure to Document and Process Missing-Item Grievance
Penalty
Summary
The facility failed to implement procedures for missing items and grievances for one resident reviewed for personal property. Resident #105 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, and the 5-Day MDS showed a BIMS score of 15, indicating intact cognition. A 24 Hour Report/Change of Condition Report documented that the resident was missing a light blue Lands' End top, size 2XL. However, the facility's Record of Concern Log for May 2025 contained no documented grievances or concerns involving the resident. During interviews, the Social Service Director stated that missing items were supposed to be handled by completing a grievance, checking the room and roommate's belongings, and contacting the family, with replacement or reimbursement handled if the item was not found. The Business Office Manager stated that missing items were to be investigated through the social worker, with inventory review and possible replacement or reimbursement, but she found no reimbursement to the resident or representative and no notes documenting a discussion about reimbursement. The Administrator stated that he expected grievances related to missing items to be handled through the grievance process.
Improper catheter care during resident hygiene
Penalty
Summary
The facility failed to ensure appropriate catheter care for one resident with an indwelling suprapubic catheter. The resident had diagnoses including other neuromuscular dysfunction of the bladder, chronic kidney disease, and presence of urogenital implants, and had severe cognitive impairment with a BIMS score of 2. The care plan identified a need for an indwelling suprapubic catheter related to neurogenic bladder and directed staff to assist with catheter care as needed and keep the tubing free of kinks and twists. The physician order required cleansing the area around the suprapubic catheter site with soap and water, rinsing and patting dry, then applying split 4x4 gauze daily and as needed. During observation, a CNA opened the resident’s incontinence brief and used wet wipes to clean the catheter insertion site, but did not secure or stabilize the catheter tubing before cleaning. The CNA then used another wipe to clean the catheter away from the resident, tugging on the tubing, and repeated the wiping steps three additional times before discarding the wipe. The facility’s catheter care policy stated that catheters should be secured to prevent pulling and damage to the urethral meatus, and the catheter care skills checklist directed staff to stabilize the catheter near the insertion point and clean the tubing starting near the insertion point and working downward. The CNA later stated he was supposed to hold the base of the catheter when cleaning it, and the DON stated staff were expected to provide catheter care according to the skills checklist.
Significant Medication Error With Premature Discontinuation of IV Antibiotic
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors related to antibiotic therapy. Resident #4 had a history of a stage 4 sacral pressure ulcer and osteomyelitis of the vertebra, sacral, and sacrococcygeal region, and the care plan identified a sacral wound infection with interventions to administer medications and treatments as ordered. The resident’s hospital discharge paperwork indicated IV ertapenem 1 gram every 24 hours through 06/22/2026, and the facility’s order recap also showed ertapenem ordered for the sacral decubitus infection. The resident’s May 2026 MAR showed no documented administration of ertapenem on 05/23/2026, 05/24/2026, 05/25/2026, and 05/26/2026. RN #16 stated she entered the antibiotic order into the computer with a discontinuation date of 05/22/2026 and confirmed the hospital discharge order had a discontinuation date of 06/22/2026, but she did not check the order herself before entering it. The DON confirmed the resident missed four doses, and the wound care physician stated she was made aware the antibiotic had been discontinued prematurely and that the medication needed to continue.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bartlett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Kings Daughters And Sons | 0 mi | ★★★★★ | 1 | 0 |
| Spring Gate Rehab & Healthcare Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Cordova Wellness And Rehabilitation Center | 5.1 mi | ★★★★★ | 6 | 0 |
| Memphis Jewish Home | 5.1 mi | ★★★★★ | 3 | 0 |
| Applingwood Post Acute | 5.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.