Colonial Manor of Randolph

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.09H Based on record review and interview: the facility failed to administer medications for Resident 1 as ordered by the Primary Care Practitioner (PCP). The sample size was 4 and the facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.11EBased on observation, record review and interview; the facility failed to store and prepare food in a manner to prevent the potential for food borne illness. This practice had the potential to affect all residents who were served snacks and meals from the kitchen. The facility identified census was 40.

Inspectors wroteLicensure Reference Number 175NAC 12-006.19(A) Based on observation, and interview; the facility failed to maintain the cleanliness and condition of walls, floors, doors, and bathrooms in 3 (North 1, 2, and 12) of 28 occupied rooms. This had the potential to affect 6 residents who resided in those rooms. The total sample size was 18 and the facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(A)(iii)(2) Based on record review and interview; the facility failed to ensure background checks were completed through the State Nurse Aide (NA) registry for 2 (NA-Q and NA-R) of 5 employees. The total sample size was 18. The facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 Based on record review and interview; the facility failed to provide evidence that a bed hold notice was provided to Resident 1 related to a hospitalization. The sample size was 2 and the facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09BBased on record review and interview; the facility failed to accurately code Resident 8's assessment related to Pre-admission Screening and Resident Review (PASRR) status. The sample size was 1 and the facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006Based on record review and interview; the facility staff failed to ensure the accuracy of the posted nursing staff hours (the total number of staff and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses (RN), Licensed Practical Nurses (LPN) Certified Medication Aide (CMA) and Certified Nurse Aides (CNA). The total sample size was 18 and the facility census was 40.

Inspectors wroteLicensure Reference number 175 NAC 12-006.04D2 Based on record review and interview; the facility failed to ensure the Dietary Manager (DM) held the required certification credentials for the position or employed a full time dietician. In addition, the facility failed to ensure staff had received training and/or were competent to serve as a cook at the facility. This had the potential to affect all residents that resided in the facility and who ate food from the kitchen. The facility census was 44.

Inspectors wroteLicensure Reference: 175 NAC 12-006.11A1 Based on observation, interview, and record review, the facility failed to follow planned menus for all residents who consumed food from the facility kitchen. The facility had a total census of 44 residents.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observations, record review and interviews; the facility failed to ensure that hot foods were served at a palatable temperature for facility residents. This had the potential to affect all 24 residents in the facility that ate food served out of the kitchen. The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(D) Based on record review and interview; the facility failed to ensure timely call light response times for residents 4, 1, and 2. The facility census was 44 and the sample size was 4.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on record review and interview; the facility failed to report an allegation of potential staff to resident abuse to the State Agency for 1 (Resident 2) of 4 sampled residents. The facility census was 44.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on record review and interview; the facility failed to investigate an allegation of potential staff to resident abuse and to submit the results of the investigation to the State Agency within the required timeframe for 1 (Resident 2) of 4 sampled residents. The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observation, record review, and interview; the facility failed to store foods to prevent the potential for food borne illness and assure food safety as staff and/or resident food items were stored in a resident refrigerator without a label and date; This had the potential to affect all residents that ate from the facility kitchen. The facility census was 38. Findings Are: Review of the Nebraska Food Code based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service and sanitation practices revealed the following: -2-401.11(A) an employee shall eat, drink . in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(B) Based on record review and interview, the facility failed to provide Resident 36 and/or the resident's representative, bed hold information when the resident was transferred to the hospital. The sample size was 1 and the facility census was 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(iii) Based on interview and record review; the facility failed to ensure Resident 30's Care Plan was revised to address suicidal ideation and failed to include mood and behavior interventions in the Care Plan for Resident 35. The sample size was 15 and the facility census was 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on observations, record review and interview; the facility staff failed to identify and/or monitor bruising and to evaluate causal factors related to the bruise for 1 (Resident 17) of 1 sampled resident. The facility identified a census of 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on interview and record review; the facility failed to ensure Resident 18's antianxiety medication had a duration for use/stop-date. The sample size was 5 and the facility census was 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observations record review and interviews; the facility failed to ensure a medication error rate of less than 5%. Observations of 31 medications revealed 2 errors resulting in an error rate of 6.45%. The errors effected 2 (Resident 25 and 21) of 3 residents. The facility census was 38.

Inspectors wroteC. Review of the facility policy Respiratory Equipment Cleaning & Storage with a revision date of 2/2019 revealed the following: -It was the policy of the facility to maintain respiratory therapy equipment in a clean and sanitary manner and to use tubing, masks, and cannulas (the nasal cannula end of the tubing fits into your nose and is the most common delivery accessory) for residents receiving therapy. -When licensed staff removed treatment, the tubing would be covered or stored in a bag. D. Review of the facility's Hand Hygiene Infection Control Policy with a revision date 10/2022 revealed the following: -It was the policy of the facility to provide the necessary supplies, education, and oversight to ensure healthcare workers performed hand hygiene based on accepted standards. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observations, record review and interview; the facility failed to prevent the potential spread of Covid-19 related to testing symptomatic residents (Resident 3, 13, and 20) and failed to ensure hand hygiene and gloving was performed at appropriate intervals during the provision of cares for Residents 22 and 27. This had the potential to affect all residents. The sample size was 18. The facility census was 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(21) Based on observation and interview; the facility failed to provide privacy during personal cares for Resident 5. The sample size was 18 and the facility census was 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on interview and record review; the facility failed to ensure as needed psychotropic medications (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood, and emotion) were limited to 14 days for Resident 5. The sample size was 5 and the census was 38.