Randolph Health Services

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 60 residents. Dish washing was completed without testing for dishwasher temperature. DA G (Dietary Aide) was observed stacking wet dishes without allowing them ample time to dry. Evidenced by:The facility's Warewashing policy, dated 9/2017, states: All dishware, serviceware, and utensils will be cleaned and sanitized after each use. 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. 2. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines.4. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 5 residents (R26) R26's surgical wound care was not completed as ordered. This is evidenced by:On 3/12/26, Surveyor requested a policy for following physician orders and treatments. NHA A (Nursing Home Administrator) stated the facility follows the Board of Nursing, Standards of Practice for Registered Nurses and Licensed Practical Nurses, which includes: N6.03(2)(d) Perform delegated acts under the general supervision or direction of provider. R26 admitted to the facility on [DATE] with diagnoses including resident reported skin cancer. R26's Minimum Data Set (MDS) dated [DATE], indicates R26 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R26 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent infections or complications for 1 of 3 Residents (R45) reviewed for catheters. R45's urinary drainage bag was noted uncovered and sitting on the floor on two separate occasions. Evidenced by:The facility's Catheter Care policy, dated 3/15/23, states, in part: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.2. Privacy/dignity bags will be available and catheter drainage bags should be covered or shielded at all times while in use. R45 admitted to the facility on [DATE] and has diagnoses that include: Urinary Tract Infection; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving misappropriation of resident funds/personal property are reported immediately to the administrator of the facility, the State agency, and to other officials, including local law enforcement, in accordance with State law through established procedures for 1 of 3 sampled residents (R3) reviewed for abuse. Facility did not report an incident of suspected resident theft/misappropriation of resident monetary funds to the local law enforcement. Evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the resident environment remains as free of accidents/hazards as is possible for 2 of 2 sampled residents (R56, R23) reviewed for accidents/hazards and 3 supplemental residents (R111, R37, R7). R56 is a cognitively impaired resident who fell out of bed onto the heat register and was there for an unknown amount of time, unable to remove herself off of the register, and sustained second- and third-degree burns. The facility made a policy for beds to remain more than 18 inches from the heat register. Surveyors observed R23, R111, R37, and R7 lying in beds that were less than 18 inches away from the heat register in the room. The facility also failed to implement a system for monitoring the surface temperature of the heat registers after the incident occurred. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents admitted without a pressure injury (PI) did not develop pressure injuries unless clinically unavoidable and did not ensure residents are provided cares and services consistent with professional standards of practice to prevent the development of PI for 1 of 4 residents (R22) reviewed for pressure injuries. R22 developed a stage 3 PI on his coccyx. The facility failed to implement a turning/ repositioning schedule that staff adhered to in order to prevent a stage 3 pressure injury and a second pressure injury from developing. Staff also did not implement the wound care treatment orders that were ordered by the physician. Evidenced by: The American Medical Directors Association (AMDA) clinical practice guideline entitled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored and distributed. This has the potential to affect all 58 residents who reside in the facility. Surveyor observed the facility's stove hood, located directly above food being prepared, to have dust covered sprinklers inside of it and 2 dust covered fixtures on the outside. Surveyor observed dented cans in circulation. Surveyor observed two gallon size milks opened and expired. Evidenced by: Example 1 Facility policy, entitled Food Storage Chart, revised 9/2017, includes: Milk, half and half and cream to be used within 4 days from open date, never longer than manufacturer expiration date. On 12/10/24 at 8:48 AM, Surveyor observed an opened gallon of 2% white milk without an open date and an expiration date of 12/9/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 58 residents. The facility does not maintain a resident infection control line list that contains residents displaying signs and symptoms of potential infection. The facility's COVID Outbreak 3/2024 summary is not complete or accurate. R31 had a breach in infection control during medication administration observation when a nurse picked up the resident's nasal cannula for oxygen from the floor and placed it into the bag on the portable oxygen tank. This is evidenced by: The facility's Infection Prevention and Control Program policy, dated 7/23/24, states in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were treated with dignity and respect in an environment that promotes an enhanced quality of life which affected 1 of 15 residents reviewed (R1). R1 reported to Surveyor that her vision is poor and that she clinks her glass against her plate in order to know where to set it, but she is unable to do that because the facility had given her a Styrofoam plate. Evidenced by: The facility's policy titled Resident Rights last reviewed on 7/2022 states in part, .12. The resident has a right to live in this facility and receive services with reasonable accommodation of needs and preferences except when to do so would endanger the health and safety of the resident or other residents . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 20 (R22) reviewed for abuse. R22 was noted to have a significant bruise to his right eye. The facility failed to report an injury of unknown origin to the State Agency. Evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that alleged violations are thoroughly investigated for 1 of 20 residents (R22) reviewed for abuse. R22 was noted to have a significant bruise to his right eye. The facility failed conduct a thorough investigation. Evidenced by: The facility's policy titled Abuse, Neglect and Exploitation last reviewed on 7/15/22 states in part, .IV. Identification of Abuse, Neglect, and Exploitation .B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. 2. Physical marks such as bruises or patterned appearances such as a handprint or ring mark on a resident's body. 3. Physical injury of a resident, of an unknown source .V. Investigation of Alleged Abuse, Neglect and Exploitation A. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that services provided by the facility meet professional standards of quality for 2 of 5 residents (R26 and R23) reviewed for unnecessary medications. R26 is receiving Melatonin for sleep and did not have a sleep assessment, sleep tracking, or a sleep care plan. R23 is receiving Melatonin for sleep and did not have a sleep assessment, sleep tracking, or a sleep care plan. This is evidenced by: Example 1: R26 was admitted to the facility on [DATE] with diagnoses that include, in part: Anxiety disorder (significant/uncontrollable feelings of anxiety); vascular dementia (type of dementia (decline in cognitive abilities) caused by decreased blood flow to the brain), without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and Bipolar Disorder. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), receives appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for 1 of 1 residents reviewed for PTSD (R14). R14 was listed as having a diagnosis of PTSD and his care plan is not person centered, as it does not specify triggers, symptoms to monitor for or interventions to use to ensure R14 is reaching his highest practical mental and psychosocial well-being. This is evidenced by: [...]