Randolph County Care Center

Inspectors wroteBased on interview and record review, the facility failed to provide enough CNAS (Certified Nurse Assistants) to ensure residents receive assistance with care including toileting in a timely manner. These failures have the potential to affect all 53 residents residing in the facility. Findings Include:1. R1's admission Record, print date of 10/27/25, documented R1 has diagnoses including malignant neoplasm of female breast, neoplasm of brain, epilepsy, cerebral infarction, and dysphagia. R1's MDS (Minimum Data Set), dated 8/29/25, documented R1 is cognitively intact although at time of interview R1 was lethargic and confused. R1's Care Plan Report, undated, documented R1 has a terminal diagnosis related to metastatic breast cancer. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to implement care plan fall interventions as documented for 2 of 3 residents (R1, R2) reviewed for falls in the sample of 6. Findings Include:1. R1's admission Record, print date of 10/27/25, documented R1 has diagnoses including malignant neoplasm of female breast, neoplasm of brain, epilepsy, cerebral infarction, and dysphagia. R1's MDS (Minimum Data Set), dated 8/29/25, documented R1 is cognitively intact although at time of interview R1 was lethargic and confused. R1's Care Plan Report, undated, documented R1 has a terminal diagnosis related to metastatic breast cancer. This care plan also documented R1 is at risk for falls with interventions including low bed at all times, 15-minute checks to ensure proper bed positioning, and floor mat with an initiation date of 10/18/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to supervise residents to prevent elopement for one of 9 residents (R2) reviewed for supervision to prevent elopements in the sample of 11. This failure resulted in an Immediate Jeopardy when on 4/11/25, R2, a resident with dementia, left without staff knowledge and was found 1 mile away from the facility. The Immediate Jeopardy began on 4/11/25 at 4:45 PM when the facility staff noticed the wander guard alarm was sounding at the front door. R2, with diagnosis with dementia and elopement risk, eloped from the facility and was found in a ditch along a busy road by a passerby at 5:22 PM per the police report. R2 admitted ly removed his (resident monitoring device) bracelet by filing it off with an emery board. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure and implement an individualized plan of care for a resident experiencing psychosocial adjustment difficulty for one of one resident (R2) reviewed for psychosocial adjustment difficulties in the sample of 11. This failure resulted in harm as evidence by R2 expressing feelings of self-harm, displaying tearfulness, and wanting to leave the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure the Director of Nursing was part of the Quality Assessment and Assurance Committee. This failure has the potential to affect all 46 residents residing in the facility. Findings Include: The Quality Assessment and Assurance Committee attendance sheet dated 03/05/25 documented the last QAA meeting had in attendance V1, Administrator, V6, Medical Director, V40, Pharmacist, V41, Medical Records consultant, and V3, Assistant Director of Nursing (ADON). There was no Director of Nursing (DON) in attendance. On 04/29/2025 at 12:11 PM, V1, Administrator, stated the facility currently doesn't have a DON. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure nurse aides completed the required 12 hours of education per year. This has the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to notify the Power of Attorney (POA)/family of a resident who was experiencing self-harm thoughts for 1 of 3 residents (R2) reviewed for self-harm in a sample of 11. Findings Include: R2's Face Sheet, print date of 04/16/25, documented R2 had diagnoses of depression and dementia. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 out of 15 and required supervision/touching assistance with ambulation. He wears a wander/elopement alarm daily. Section D of the MDS documented under the symptom's presence R2 was having feelings of feeling down, depressed, or feeling hopeless. Under the symptoms frequency documented he was having these feelings 12-14 days (nearly every day). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate staffing to provide supervision for 1 of 4 residents (R2) reviewed for sufficient staffing in a sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's coffee was served at safe temperatures to prevent burns/injury. This failure resulted in an Immediate Jeopardy when R21 sustained a second degree burn from spilling hot coffee on himself on 2/8/2024 and the facility continued to provide all residents' coffee at unsafe temperatures.

Inspectors wroteBased on interview and record review the facility failed to ensure abuse did not occur for 2 of 3 residents (R9 and R149) reviewed for abuse in the sample of 31.

Inspectors wroteBased on interview and record review the Facility failed to ensure all abuse allegations were investigated thoroughly and completed for 1 of 4 residents (R149) reviewed for abuse in the sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) at least 8 consecutive hours, 7 days a week. This has the potential to affect all 49 residents who reside at this facility. This past non-compliance occurred between 7/2/22 and 9/20/22.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall interventions for 1 of 4 residents (R33) reviewed for accidents in the sample of 25. This failure resulted in R33 suffering a fall resulting in a subdural hematoma requiring hospitalization for monitoring and treatment. Findings Include: R33's admission Record documents R33's original admission date to facility as 1/3/22. R33's Minimum Data Set (MDS) dated [DATE] documents a BIMS score of 09, indicating cognitive impairment. This same MDS documents in Section G0110 that R33 requires limited assistance from 1-person physical assist for transfers, walking in room, and walking in corridor. R33's Morse Fall Scale dated 1/3/22 documents a score of 75, indicating R33 is at high risk for falls. [...]

Inspectors wroteBased on interview, and record review the facility failed to provide 8 hours of daily Registered Nurse coverage. This failure has the potential to affect all 43 residents residing in the facility. Findings Include: On 2/17/22 at 10:20 am, V2 (Director of Nursing) acknowledges there are days that the facility does not have Registered Nurse (RN) coverage. V2 states that the facility has two Registered Nurses employed at the facility, V13 and V14 (Registered Nurse), but since the beginning of the year they have worked on the same weekend, which then leaves the opposite weekend with no RN coverage. V2 verifies the accuracy of nursing schedules provided and states the facility does not have any nursing waivers. Review of the Nursing Schedules from 2/1/22- 3/28/21 documents no RN coverage was provided at the facility on 2/1/22, 2/5/22, 2/6/22, and 2/15/22. [...]

Inspectors wroteBased on observation, interview, and record review failed to accommodate residents' food preferences for 8 of 12 residents (R14, R22, R23, R24, R25, R27, R28, and R43) reviewed for preferences in a sample of 25. The Findings Include: 1. On 2/17/22 at 1:10 pm, R25 and R28 were seated in the dining room with their lunch plate still on the table. Both resides were alert to person, place and time R28 stated that R28 asked for sliced onion for R28's ham today and V8 (Dietary Aide) told him They were fresh out. R28 went on to state that R28 never gets what R28 asks for during the meals. R28 stated that today at lunch R28 also asked for some juice for the ham and the black-eyed peas but no one would give R28 any. R25 and R28 further stated that they do not know what they have to offer other than what is served. [...]

Inspectors wroteBased on record review and interview, the facility failed to operationalize its Abuse Policy by thoroughly investigating an incident of resident-to-resident sexual abuse and reporting the incident to law enforcement as stated in the policy for 2 of 2 residents (R3, R24) reviewed for abuse in the sample of 25.

Inspectors wroteBased on record review and interview, the facility failed to report an incident of resident-to-resident sexual abuse to local law enforcement for 2 of 2 residents (R3, R24) reviewed for abuse in the sample of 25.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an incident of resident-to-resident sexual abuse for 2 of 2 residents (R3, R24) reviewed for abuse in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident and/or resident's representatives in writing of hospital transfers for 3 of 3 residents (R1, R3, R33) reviewed for hospitalizations in a sample of 25. Findings Include: 1. Review of R33's admission Record documents R33's original admission date to the facility as 1/3/22. This same document lists V10 (Resident Representative) as R33's responsible party. On 2/15/22 at 10:36 pm, R33 was alert to person only. Review of R33's Clinical Record documents an entry on 1/17/22 at 5:45 pm which states R33 was found lying on the floor on R33's back. R33 knows R33's name but unable to explain how R33 got on the floor. Neurological flow sheet started due to 3.0 cc (cubic centimeter) hematoma on left, upper, back of head. Blood pressure and pulse elevated. Order received to send to local hospital for evaluation and treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of the facility's Bed Hold policy to a resident and/or resident's representative at the time of a resident transfer to the hospital for 3 of 3 (R1, R3, R33) residents reviewed for hospitalization in the sample of 25. Findings Include: 1. Review of R33's admission Record documents her original admission date to the facility as 1/3/22. This same document lists V10 (Resident Representative) as R33's responsible party. On 2/15/22 at 10:36 am, R33 is alert to person only. Review of R33's Clinical Record documents an entry on 1/17/22 at 5:45 pm which states R33 was found lying on the floor on R33's back. R33 knows R33's name but unable to explain how R33 got on the floor. Neurological flow sheet started due to 3.0 cc (cubic centimeter) hematoma on left, upper, back of head. Blood pressure and pulse elevated. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to develop and implement a Plan of Care encompassing Dementia Care Services for 2 of 12 residents (R3, R33) reviewed for Care Planning in the sample of 25.