Care One at Randolph

Inspectors wroteBased on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify the Physician/Nurse Practitioner (NP)/Resident Representative timely of a change in condition for three Residents (#71, #132 and #24), out of a total sample of 32 residents. Specifically, the facility failed:1. For Resident #71, to notify the Physician/NP: a. when the Resident had a new onset of auditory hallucinations and alleged suicide attempt (pulled out dialysis fistula - a surgically created connection between an artery and a vein, typically in the arm, used to provide access for hemodialysis (a treatment that filters waste from the blood when the kidneys fail) during dialysis treatment at an outpatient dialysis center, and b. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Level I Pre-admission Screening and Resident Review (PASARR) for three Residents (#1, #5, and #8), out of a total sample of 32 residents, resulting in the Residents being admitted to the facility without the determination of whether they screened positive for intellectual disability (ID)/developmental disability (DD) or serious mental illness (SMI) requiring further evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement and individualize comprehensive care plans for three Residents (#71, #33, and #8), out of a total sample of 32 residents. Specifically, the facility failed:1. For Resident #71, to develop and implement a person-centered care plan with measurable objectives and timeframes: a. to address recent onset of auditory hallucinations and self-injurious behavior/alleged suicide attempt; andb. to address the use of Sertraline (selective serotonin reuptake inhibitor used to treat anxiety) and Lorazepam (antianxiety) that identified resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment;2. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide services that met professional standards of practice for seven Residents (#28, #43, #39, #5, #4, #71, and #1), out of a total sample of 32 residents. Specifically, the facility failed: 1. For Resident #28, to ensure vital sign parameters were adhered to prior to medication administration as per physician's orders;2. For Resident #43, to ensure his/her left built-up palm guard was implemented per physician's orders;3. For Resident #39,a. To ensure hospital medication reconciliation was completed and medications were implemented, andb. To ensure his/her air settings and right heel off-loading boots were implemented per physician orders;4. For Resident #5, to ensure his/her right-hand carrot orthotic and left-hand palm guard were implemented per physician's orders;5. [...]

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide care, consistent with professional standards of practice for one Resident (#39), out of a total sample of 32 residents. Specifically, the facility failed to ensure his/her wound (non-pressure related) recommendations were implemented.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two Residents (#33 and #7), in a sample of 32 residents, were seen by the Physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner (NP) as indicated. Specifically, the facility failed:1. For Resident #33, to ensure the Resident was seen by the Physician or NP at least every 60 days after the first 90 days after admission; and2. For Resident #7, to ensure the Resident was seen and evaluated by a Physician or NP at least every 60 days.

Inspectors wroteBased on observation, and interview, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable professional standards for one Resident (#39), of 32 sampled residents and in four of five medication carts observed. Specifically, the facility failed to:1. For Resident #39, ensure Dakins Solution (a dilute solution of sodium hypochlorite (bleach) historically used as an antiseptic for wound cleaning) was stored in a locked compartment;2. On the 3 East Unit, ensure the medication cart was locked and secured while unattended; and3. Ensure that medications and biologicals were stored in accordance with professional standards of practice in three of four observed medication carts.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Properly label and date food products and maintain safe/clean equipment in four of four unit nourishment kitchenettes; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed:1. To maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; 2. For Resident #10, to ensure the tubing for a gastrostomy tube (g-tube, a feeding tube inserted through the abdominal wall) was not in contact with the tubing for a urinary catheter;3. For Resident #17, to ensure nasal cannula (NC) tubing for oxygen delivery through the nose, was stored in a sanitary way to prevent the possibility of contamination from germs when not in use; 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education, assess eligibility, and offer influenza (flu) vaccinations and pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for four Residents (#28, #39, #9, and #90), out of a sample of five residents. Specifically, the facility failed to ensure:1. Staff offered, assessed, and provided education on the CDC recommended pneumococcal vaccines (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria) for Residents #28, #39, #9, and #90; and2. Staff administered the seasonal influenza vaccine to Resident #90 who had a signed consent form to receive the vaccine.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#132) had the right to participate in his/her discharge planning process, in a total sample of 32 residents. Specifically, the facility involved the family member of Resident #132 in the discharge planning and did not involve Resident #132 who remained his/her own healthcare decision maker.

Inspectors wroteBased on record review and interviews, the facility failed to ensure for one Resident (#71), out of a sample of 32 residents, that informed, written consent was obtained for the administration of psychotropic medications, which include providing the Resident with information related to the risks and benefits of the medications, prior to administering them.

Inspectors wroteBased on interview and document review, the facility failed to promptly resolve a grievance for a missing delivery for one Resident (#17), out of a total sample of 32 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure for one Resident (#33), from a total sample of 32 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed for Resident #33, to ensure a gradual dose reduction (GDR) was attempted, unless documented by the prescriber as clinically contraindicated in the medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one Resident (#101), out of a total sample of 32 residents, that footcare was provided in accordance with professional standards to help prevent potential foot problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for one Resident (#132), in a total sample of 32 residents. Specifically, the facility failed to identify and intervene when the facility staff were writing secure keypad codes on door frames, including a stairwell where Resident #132, who was at risk for falls, at risk for wandering, at risk for eloping, and was experiencing confusion, accessed and descended 26 concrete stairs which lead to an alarmed exit door.

Inspectors wroteBased on record review and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one Resident (#71), out of a total sample of 32 residents. Specifically, the facility failed to ensure that Resident #71's Behavioral Health Services providers were informed and provided appropriate psychiatric follow-up when the Resident was sent to the emergency room from the dialysis center for a concern of a suicide attempt after hearing auditory hallucinations, verbalizing wanting to die, and pulling out a dialysis line.

Inspectors wroteBased on document review and interview, the facility failed to ensure monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for two Residents (#33 and #15), out of a total sample of 32 residents. Specifically, the facility failed:1. For Resident #33, to ensure April 2025 consultant pharmacist recommendations were provided to the physician/nurse practitioner (NP) for review and response to the recommendation; and2. For Resident #15, to maintain the facility policy of documenting monthly MRR in the medical record, ensure the physician documented review of the April 2025 irregularity in the medical record and ensure the irregularity was addressed timely.

Inspectors wroteBased on record review and interview, the facility failed to ensure laboratory results were reported and acted on timely for one Resident (#9), out of a total sample of 32 residents. Specifically, the facility failed to report his/her 6/12/25 and 6/20/25 sodium (a vital electrolyte that helps regulate fluid balance, blood pressure, nerve and muscle function with a reference range of 136 to 145 milliequivalents per liter (mEq/L) levels to the provider resulting in a delayed hospital transfer on two occasions.

Inspectors wroteBased on record review and interview, the facility failed to provide written documentation related to transfer discharge notices and bed hold upon hospitalizations or discharge for three Residents (#142, #143, and #9), out of a total of 32 sampled residents and 3 closed records.

Inspectors wroteBased on records reviewed and interviews for two of six sampled residents (Resident #5 and #6), who were alert, oriented, and able to make their own health care decisions, the Facility failed to ensure that they obtained signed written consent for the administration of psychotropic medications, which include providing each resident with information related to the risks and benefits of the medications, prior to administering them.

Inspectors wroteBased on records reviewed, interviews, and observations for three of five sampled residents (Resident #1, #2 and #4) and three non-sampled residents (NS RT #A, #B and #C), the facility the Facility failed to ensure 1) that the call bell system button was accessible and within reach for residents to call for assistance and 2) that staff responded to sounding call bells in a timely manner, per facility policy.

Inspectors wroteBased on records reviewed and interviews, for two of six sampled residents, (Resident #3 and #5), the facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals and outcomes that addressed the residents' overall immediate care needs.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who had experienced a change in condition related to an incident of elopement, the Facility failed to ensure that nursing notified Resident #2's Health Care Agent (HCA, Family Member #3 aka, his/her Resident Representative), when on 02/21/25 at approximately 5:45 A.M., an individual that had dropped off a staff member for work, found a person (later identified as Resident #2) outside the Facility sitting on the pavement in the middle of the facility's driveway, and Family Member #3 was not made until much later that day (around 2:00 P.M.) when she came into visit Resident #2 and questioned staff about the areas of bruising to Resident #2's knees.

Inspectors wroteBased on records reviewed, interviews and for two of three unit kitchenettes, the facility failed to ensure they maintained a pest free environment, when live and dead cockroaches were observed during an environmental tour on the units.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had a diagnosis of diabetes mellitus and received two oral hypoglycemic medications daily, the Facility failed to ensure nursing developed and implemented an individualized comprehensive care plan with interventions, treatment goals and outcomes that addressed Resident #1's risk for hyper/hypoglycemia (high/low blood sugar).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a diagnosis of diabetes mellitus and received two oral hypoglycemic medications daily, the Facility failed to ensure nursing staff provided care and services that met professional standards of quality related to monitoring and assessment of Resident #1 for signs and symptoms of hyper/hypoglycemia (high/low blood sugar).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing immediately notified his/her Health Care Agent (HCA) and physician, when on 09/20/24, Resident #1 was found sitting on the floor after an unwitnessed fall. Resident #1 was noted with a closed, swollen, puffy right eye several hours later and was transferred to the Hospital Emergency Department (ED) for evaluation.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plans of Care indicated that he/she required the physical assistance of one staff member with transfers and ambulation, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in their Plans of Care, when on 09/20/24, a short time after Resident #1 had been found on the floor by staff after an unwitnessed fall, Nurse #1 witnessed Resident #1 walking in his/her room, unassisted, and did not intervene to assist him/her, did not notify a staff member that he/she was ambulating in his/her room without assistance and proceeded to leave the facility and go home.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, required supervision to substantial/maximal assistance from staff to meet his/her care needs, and was assessed by nursing as being at high risk for falls, the Facility failed to ensure he/she was provided nursing care and treatment in accordance with professional standards of practice, when on 09/20/24, after Resident #1 was found lying on the floor in his/her room by Certified Nurse Aide (CNA) #1 after an unwitnessed fall, CNA #1 proceeded get him/her up off the floor, walk him/her to the bathroom and then transfer him/her back to bed, before informing and having nursing assess him/her for any potential injury. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired and was assessed by nursing at high risk for falls, the Facility failed to ensure staff provided quality of care consistent with professional standards of practice, when on 09/20/24, after finding Resident #1 lying on the floor in his/her room after an unwitnessed fall, Certified Nurse Aide (CNA) #1 got him/her up off the floor, proceeded to walk with him/her to the bathroom and transfer him/her back to bed, before informing and having the nurse assess him/her for the potential for physical injury, and as a result, Resident #1 was found in bed the next morning with a swollen, puffy, closed right eye and was transferred to the Hospital Emergency Department (ED) for evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to honor a choice of smoking for two Residents (#424 and #425), out of a total sample of 25 residents.

Inspectors wroteBased on observation, test tray results, and interview, the facility failed to ensure staff served food that was palatable and at an appetizing temperature for 2 out of 2 test trays conducted.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure that staff accommodate food preferences for two Residents (#18 and #37), out of a total sample of 25 residents. Specifically, 1. For Resident #18, the facility failed to offer preferred food and portion size requested by the Resident, which included scrambled eggs and double meal portions. 2. For Resident #37, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including coffee and oatmeal, on a daily basis.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure two of four-unit kitchenettes were maintained in a clean and sanitary condition; and 2. Ensure food items were properly labeled, dated, and stored four of four-unit kitchenettes.

Inspectors wroteBased on document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections for four Residents (#59, #104, #1A, and #74) of 25 sampled residents and for three of four units in the facility. Specifically, the facility failed to: 1. For Resident #59, ensure staff wore personal protective equipment (PPE) as required for Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) while providing direct care to a Resident requiring tube feeding; 2. For Residents #104 and #1A, ensure staff wore PPE as required for contact precautions (an infection control intervention designed to reduce transmission of infections) while providing care; and 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure advanced directives were reviewed and followed-up on for one Resident (#44), out of 25 sampled residents. Specifically, the facility failed to ensure the wishes for Do Not Resuscitate (DNR) were pursued as legally allowed for Resident #110.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Physician/Practitioner was notified of a change in treatment for one Resident (#59), out of a total sample of 25 residents. Specifically, the facility failed to ensure the Physician/Practitioner was notified when an antibiotic prescribed to treat a urinary tract infection (UTI) was not available from the pharmacy and administered as ordered.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff developed a baseline or comprehensive care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care for two Residents (#424 and #425), out of a total sample of 25 residents. Specifically, the facility failed: 1. For Resident #424, to develop a baseline care plan for the Resident's diagnosis of diabetes mellitus and sarcoidosis; and 2. For Resident #425, to develop and implement a baseline care plan related to falls.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff provided care and services consistent with accepted standards of clinical practice for two Residents (#59 and #47), out of a total sample of 25 residents. Specifically, the facility failed to ensure: 1. For Resident #59, a. the Physician's order for antibiotics to treat a urinary tract infection (UTI) was implemented timely which resulted in a delay in treatment and was administered for the duration of the order; and b. the Physician's order was followed for tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) and measuring gastric volume; 2. For Resident #425, care and treatment to the Resident's implanted cardiac pacemaker met professional standards of quality.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#65), out of a total sample of 25 residents. Specifically, the facility failed to fully develop and implement interdisciplinary care plans related to his/her dominant language of Cantonese and failed to implement their Limited English Proficiency policy.

Inspectors wroteBased on observation, record review and interview for one Resident (#276) of 25 sampled residents the facility failed to ensure acceptable parameters of nutritional status were maintained. Specifically, for Resident #276 a resident with nutritional risk factors, the facility failed to timely obtain a reweigh when significant weight loss was identified.

Inspectors wroteBased on records reviewed, interviews and observations for one of four sampled resident care units (2 East), the Facility failed to ensure food and beverages provided to the residents were served at safe and appetizing temperatures, when on 05/28/24, results of test trays observations indicated that the food items were not served at appetizing temperatures, and some foods items were not palatable.

Inspectors wroteBased on records reviewed, interviews and observations for one of three sampled residents (Resident #1), the Facility failed to ensure nursing provided care and services that met professional standards, when on 05/28/24, nursing failed to follow acceptable standards of practice related to medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and prevent a left knee contracture from developing after resident completed the initial course of physical therapy for one Resident (#106), out of a total sample of 28 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the nourishment kitchenettes were maintained in a clean sanitary manner to prevent potential foodborne illness for 4 out of 4 nourishment kitchenettes.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure 1) a medication cart was locked, 2) medications were stored (refrigerated), and dated once opened, according to manufacturer's guidelines in three out of seven medication carts and 3) medication room was maintained according to facility policy.

Inspectors wroteBased on observation, interview, and test tray results, the facility failed to ensure foods and beverages were prepared by methods which conserved nutritional value, flavor, appearance, palatability, and appetizing temperatures for one of two test trays observed.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic medications prior to their use for one Resident (#20) out of a total sample of 28 Residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and implemented for two Residents (#33 and #4), out of a total sample of 28 residents. Specifically, the facility failed to: 1) For Resident #33 implement bilateral quarter side rails used for mobility and security; and, 2) For Resident #4 ensure a comprehensive care plan was developed for a resident receiving Dialysis treatment.

Inspectors wroteBased on record review, policy review and interview, the facility failed to ensure staff administered medication which met professional standards of care for one Resident (#21) out of a total sample of 28 residents. Specifically, staff failed to follow the Physician's order, and administered medication when the Resident's blood pressure was outside the Physician's ordered parameters.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff provided appropriate care and services related to indwelling urinary catheter drainage bags for one Resident (#120) who required an indwelling urinary catheter (a tube placed through the urethra into the bladder to drain urine), out of a total sample of 28 residents.

Inspectors wroteBased on observations, records review, interview and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube, a feeding tube in the abdomen used to provide nutrition) was provided in accordance with professional standards of practice for two Residents (#120 and #52), out of a total sample of 28 residents. Specifically, 1.) For Resident #120, nursing administered an enteral nutrition formula which was not correct, the bottle was undated and therefor unable to ensure the enteral nutrition was not expired and 2.) For Resident #52, the enteral bottle was undated and therefor unable to ensure the enteral nutrition was not expired. Review of the facility policy titled, Enteral Feedings - Safety Precautions, dated as [DATE], indicated but was not limited to the following: -To ensure the safe administration of enteral nutrition: *Preparation 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and maintenance of an intravenous catheter, consistent with professional standards of practice for one Resident (#227) out of a total sample of 28 residents. Specifically, for Resident #227, the facility failed to flush his/her intravenous device to maintain patency. Findings Include: Review of the facility policy titled, Maintaining Patency of Peripheral and Central Vascular Access Devices, dated 8/16, indicated, but was not limited to: -All vascular access devices should be flushed routinely when not in use to maintain patency. Review of the facility policy titled, Infusion Therapy Procedures Flush Chart, dated 8/16, indicated but was not limited to: -For a tunneled Catheter at a minimum should be flushed with 10 milliliters (mL) of saline pre- use, post-use, every eight hours and as needed. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain respiratory equipment according to professional standards of practice for 1 Resident (#120) out of a total sample of 28 residents.

Inspectors wroteBased on observations, records reviewed, policy review and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 3 nurses observed made 2 errors out of 25 opportunities resulting in a medication error rate of 8%. Those errors impacted 2 Residents (#115 and #21) out of 3 residents observed.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#276) was free from a significant medication error, out of a total sample of 28 residents. Specifically, Resident #276 was administered the physician's ordered antibiotic daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M.; for 26 doses instead of every eight hours as indicated by the hospital discharge summary.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure staff implemented and followed facility policy for proper Enhanced Barrier Precautions in an effort to help prevent the possible transmission of diseases and infections, such as multi-drug resistant organisms (MDROs) for two Residents (#73 and #115) out of a total sample of 28 residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain essential equipment in the main kitchen in working order. Specifically, the facility failed to: 1. Ensure the dishwasher sanitation rise temperature reached 180 degrees Fahrenheit as required for sanitation process to be completed; and, 2. Ensure the steam oven was repaired in a timely manner.