Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Manor Of Randolph during CMS and state inspections, most recent first.
A resident with diabetes and multiple chronic conditions had a standing sliding scale Humulin insulin order requiring specific doses for blood glucose levels over 400. Facility policy required medications to be administered per PCP orders. On several occasions, the resident’s blood glucose readings were significantly elevated, yet the medical record contained no evidence that insulin was administered or what dose, if any, was given. The DON and an RN consultant confirmed there was no documentation that the ordered sliding scale insulin was provided at those times.
Undated refrigerated food items were observed in the kitchen, including 2 bags of bologna and 7 salami/cheese sandwiches in the snack container. Facility policy required food to be labeled and dated when opened or prepared, and the Dietary Manager confirmed items were to be discarded 3 days after the open date.
Unclean and Damaged Resident Bathrooms and Room Surfaces: The facility failed to maintain the condition and cleanliness of bathrooms and room surfaces in 3 occupied rooms. Issues included holes in walls and doors, missing floor covering with exposed concrete and drywall, uncovered bedpans and incontinence products stored on the floor, and dark brown stains with a fecal odor in one resident bathroom. The Administrator confirmed the areas needed repair and/or cleaning, and the Maintenance Supervisor stated no work orders had been completed for the concerns.
Failure to Document Bed Hold Notice for a Hospitalized Resident: The facility did not have evidence that a bed hold notice was offered or completed for a resident who was transferred to the hospital and later returned after a brief stay. The resident was cognitively intact and required assistance with toileting, dressing, and mobility; diagnoses included debility, HTN, pneumonia, bladder infection, and DM. An LPN reported the hospitalization involved COVID-19 and a bladder infection, and the Social Services Director confirmed there was no evidence the resident or representative was offered a bed hold.
Inaccurate PASRR Coding on MDS: The facility failed to accurately code a resident’s Comprehensive MDS to reflect a PASRR Level II Determination. The resident had moderate cognitive impairment, multiple diagnoses including anxiety, depression, psychotic disorder, seizures, and paralysis, and the record showed an ID or related condition with NF services required and appropriate. The DON confirmed the MDS did not match the PASRR finding.
Failure to Complete NA Registry Background Checks: The facility failed to complete State NA Registry background checks for two dietary aides before hire. Facility policy required screening to identify any negative findings related to abuse, neglect, exploitation, mistreatment, or misappropriation, and the Administrator confirmed the checks were not completed upon employment.
Inaccurate Posting of Nursing Staff Hours: The facility failed to ensure the daily posted nursing staff hours were accurate. Record review showed the posted RN and LPN hours did not match the nursing schedule for reviewed shifts, and the DON and Administrator confirmed the professional nursing hours included staff working in the ALF and were not removed from the posted nursing staff hours.
The facility did not ensure that the Dietary Manager held the required certification or that a full-time dietician was employed. The Operations Manager, lacking necessary training, served as both interim DM and cook, and menu substitutions were made due to improper food ordering. Dietary staff did not receive adequate training or demonstrate competency, affecting all residents receiving meals from the kitchen.
The facility did not serve meals according to the planned and approved menus, instead substituting available food items due to insufficient ordering by an untrained interim Dietary Manager. The interim manager did not consult with the Registered Dietician regarding these changes, resulting in all residents receiving meals that differed from the posted menu.
The facility did not consistently obtain or document food temperatures for meals, as required by policy, with multiple instances where hot foods were reheated and served to residents without temperature checks. Dietary staff confirmed the omission of temperature monitoring and documentation, which affected all residents receiving food from the kitchen.
Multiple residents with significant care needs experienced prolonged delays in call light responses, with documented wait times frequently exceeding the facility's 10-minute standard. Residents dependent on staff for mobility, toileting, and hygiene reported waiting up to an hour for assistance, particularly during evening shifts. Interviews and records confirmed that insufficient staffing contributed to these delays, and grievances regarding the issue were not investigated or resolved.
A resident reported feeling threatened by an OM, who stated the resident would be discharged to a homeless shelter if an outstanding bill was not resolved. The resident informed the SSD, who acknowledged the concern as verbal abuse but failed to report the allegation to the State Agency or notify facility leadership, as required by policy.
A resident reported feeling threatened by an Operations Manager who stated that unresolved billing issues could result in discharge to a homeless shelter. The Social Service Director did not notify the Administrator or initiate an investigation, and the incident was not reported to the State Agency as required by policy.
The facility failed to label and date food items stored in a resident refrigerator, as observed during a kitchen tour. Items such as a juice-like drink, tomatoes, a sandwich, and a container with mixed food were found without proper labeling. The Operations Manager confirmed that these items should have been labeled and dated, posing a potential risk to the 38 residents consuming food from the facility kitchen.
A facility failed to provide a resident and/or their representative with the required bed hold information when the resident was transferred to the hospital. The facility's policy mandates that written information regarding the bed hold provision be given at admission and before hospital transfers, or within 24 hours in emergencies. A review of the resident's records showed no evidence of such notification, which was confirmed by the facility's administrator.
The facility failed to revise care plans for two residents who expressed suicidal ideation. One resident, with complex medical conditions, expressed self-harm thoughts, but their care plan lacked interventions for these concerns. Another resident, with depression and other diagnoses, also expressed self-harm thoughts, but their care plan did not document these or include necessary interventions. The DON confirmed the omissions in both cases.
A resident with severe cognitive impairment and a history of stroke and hemiplegia was found to have a large bruise on the left hand, which was not documented or monitored by the facility staff. Despite being reported by a nurse aide, the bruise was not included in the Weekly Skin Evaluations, and no causal factors were evaluated. The facility's care plan interventions for skin monitoring were not followed, indicating a lapse in procedure adherence.
A facility failed to document a stop date for a PRN order of Lorazepam for a resident with severe cognitive impairment and multiple diagnoses, including anxiety and seizures. The facility's policy requires PRN psychotropic medications to have a stop date or documented duration, which was not adhered to, as confirmed by the DON and ADON.
A facility failed to maintain a medication error rate below 5%, with errors affecting two residents. An LPN did not expel air from an insulin pen before administering the dose to a resident, and an RN administered Pantoprazole to another resident only 9 minutes before a meal, contrary to the physician's order.
The facility failed to adhere to infection control protocols, with staff not wearing PPE correctly, improper storage of a resident's oxygen equipment, and inadequate hand hygiene practices. An RN was observed with a mask below their nose, and a CNA did not change gloves or wash hands during care. Additionally, a resident's urinal was stored next to food, violating infection control practices.
Failure to Administer Ordered Sliding Scale Insulin
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to administer insulin as ordered by the primary care practitioner for a resident with multiple chronic conditions. Facility policy required that medications and treatments be administered only upon written orders from authorized prescribers and that all medications, treatments, and procedures be administered per physician order. The resident’s Minimum Data Set dated 2/19/26 showed the resident was cognitively intact, required substantial assistance with several activities of daily living, and received insulin injections and a diuretic daily during the assessment period. The resident had diagnoses including chronic kidney disease, heart failure, hypertension, diabetes, Parkinson’s disease, depression, and anxiety. A physician order dated 9/17/25 directed sliding scale Humulin insulin dosing based on blood glucose levels, with 12 units to be given for blood sugars greater than 400. Record review showed multiple instances where the resident’s blood glucose readings were significantly elevated without documented administration of insulin as ordered. On 10/5/25 at 5:00 PM, the resident’s blood sugar was 561, with no evidence in the medical record that any insulin was administered or what dose, if any, was given. On 10/6/25 at 11:00 AM, the resident’s blood sugar was 461, with no documentation that the ordered 12 units of insulin were given. On 10/10/25 at 7:00 AM and again at 11:00 AM, the resident’s blood sugar was 499 on both occasions, with no evidence that insulin was administered or what dose was provided. In an interview, the DON and the RN consultant confirmed there was no evidence that the resident received the ordered sliding scale insulin at these times.
Undated refrigerated food items observed in kitchen
Penalty
Summary
The facility failed to store and prepare food in a manner to prevent the potential for food borne illness. During the initial kitchen tour, surveyors observed prepared food items in the refrigerator that were undated, including 2 bags of bologna meat and 7 salami/cheese sandwiches in the snack container. The facility policy stated that food should be stored, prepared, distributed, and served in accordance with professional standards for food service safety, and that foods requiring refrigeration should be refrigerated immediately upon receipt, labeled, dated, and monitored for use by the use-by date. The Dietary Manager confirmed that all food items were to be labeled and dated when opened or prepared and disposed of 3 days after the open date.
Unclean and Damaged Resident Bathrooms and Room Surfaces
Penalty
Summary
The facility failed to maintain the cleanliness and condition of walls, floors, doors, and bathrooms in 3 occupied rooms, North 1, North 2, and North 12. In the bathroom of North 1, there was a hole in the wall between the stool and handwashing sink measuring approximately 3 cm by 6 cm with exposed piping visible. In North 2, the bathroom door had a scraped area with a hole, the concrete floor under the handwashing sink had missing linoleum, two uncovered bedpans and a package of disposable urinary incontinence products were stored directly on the concrete, and the wall covering around the handwashing sink had been removed with exposed drywall. In North 12, the stool and stool riser had dark brown stains, and there was a pervasive smell of feces in the resident's room and bathroom. The Administrator confirmed the areas needed repair and/or cleaning, and the Maintenance Supervisor stated that no work orders had been completed regarding the concerns in the North corridor resident rooms.
Failure to Document Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide evidence that a bed hold notice was given to Resident 1 related to a hospitalization. The facility policy on bed holds, dated 12/2023, required the resident or resident representative to be informed in writing of the right to exercise the bed hold provision upon admission and to receive a second notice before transfer to a general acute care hospital or before therapeutic leave, with a copy of the notification maintained in the resident’s health record at the time of transfer. The notice was also required to include the duration of the bed-hold policy, the amount required to hold the bed, and information that insurance may or may not cover the costs. Resident 1’s record showed a discharge assessment with anticipated return and an entry assessment, and the resident was cognitively intact with assistance needs for toileting, dressing, and mobility. Diagnoses included debility, high blood pressure, pneumonia, bladder infection, and diabetes. Review of the medical record, including progress notes, care plan, and scanned documents, found no evidence that a bed hold was offered or completed. An LPN reported that Resident 1 was hospitalized in early October 2025 with COVID-19 and a bladder infection, remained in the hospital for a couple of days, and then returned to the facility. The Social Services Director confirmed there was no evidence that the resident or representative was offered a bed hold when the resident was transferred to the hospital.
Inaccurate PASRR Coding on MDS
Penalty
Summary
The facility failed to accurately code Resident 8’s assessment related to PASRR status. Review of the facility’s Preadmission Screening policy showed that a PASRR was to be completed on every resident upon admission and as needed, with referrals made to the appropriate State agencies when specialized services were identified. However, the resident’s Comprehensive MDS did not indicate a PASRR Level II Determination even though the resident had a PASRR Level II Determination dated 5/2/23. Resident 8’s record showed the resident was admitted with moderate cognitive impairment, limitations in upper and lower extremity range of motion, and dependence on staff for toileting, dressing, personal hygiene, and mobility. Diagnoses included cancer, high blood pressure, paralysis affecting one side of the body, seizures, anxiety, depression, and psychotic disorder. The care plan documented impaired cognitive function related to a traumatic brain injury, mood disturbance related to depression and anxiety, and behaviors such as resistive with cares. The PASRR Level II Determination identified the resident as having an intellectual disability or related condition and stated the resident required and was appropriate for nursing facility services. The DON confirmed that the Comprehensive MDS was not coded accurately to reflect the PASRR Level II Determination.
Failure to Complete Nurse Aide Registry Background Checks
Penalty
Summary
The facility failed to ensure background checks were completed through the State Nurse Aide registry for 2 of 5 employees reviewed, identified as Dietary Aide-Q and Dietary Aide-R. The facility policy on Freedom from Abuse, Neglect, Exploitation and Misappropriation stated that the facility would not knowingly employ or otherwise engage any individual who had a negative finding in the State Nurse Aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property. Record review showed Dietary Aide-Q was hired without evidence that a State Nurse Aide Registry background check had been completed prior to the hire date. Record review also showed Dietary Aide-R was hired without evidence that a State Nurse Aide Registry background check had been completed prior to the hire date. During interview, the Administrator confirmed the facility failed to check the Nurse Aide Registry upon employment for both employees to ensure there were no negative findings and that residents were protected from potential abuse.
Inaccurate Posting of Nursing Staff Hours
Penalty
Summary
The facility failed to ensure the accuracy of the posted nursing staff hours for the daily nursing staff information. Record review showed that the posted totals for RN, LPN, CMA, and CNA hours did not match the nursing schedule for the shifts reviewed. On 12/08/25, the 6 AM to 2 PM posting listed 2 RNs, 2 LPNs, and 6 CNAs/CMAs, while the nursing schedule showed 2 LPNs and 6 CNAs caring for residents. The 2 PM to 10 PM and 10 PM to 6 AM postings were also reviewed, with the schedule reflecting the nursing staff actually assigned for those shifts. On 12/09/25, the 6 AM to 2 PM posting listed 3 RNs, 3 LPNs, and 5 CNAs/CMAs, but the nursing schedule showed 2 LPNs and 5 CNAs. The 2 PM to 10 PM and 10 PM to 6 AM postings were reviewed as well, and the schedule matched the staff working those shifts. During interview on 12/09/25 at 3:15 PM, the DON and Administrator confirmed that the posted professional nursing hours included all RNs and LPNs working in the facility that day, that this was not completed correctly, and that hours worked in the ALF were not removed from the posted nursing staff hours.
Failure to Employ Qualified Dietary Staff and Maintain Menu Standards
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, as required by regulation. Specifically, the Dietary Manager (DM) position was vacant after the previous DM left, and the Operations Manager (OM), who lacked the required certification and training, was serving as the interim DM. The OM also worked as a cook without having received any training for the DM or cook roles and had not consulted with the Registered Dietician regarding menu changes. Additionally, the facility did not employ a full-time dietician, and dietary staff had not received adequate training or demonstrated competency to serve as cooks. Record review and staff interviews revealed that the OM was responsible for ordering food and, due to insufficient ordering, the facility was unable to follow the preapproved/planned menus. Instead, available food from the freezers and storeroom was used as substitutes. The dietary schedule showed the OM frequently filled in as a cook due to staffing shortages, and the Interdisciplinary Team (IDT) assisted with dietary aide duties, receiving only limited training related to dishwasher safety and temperature logs. These deficiencies had the potential to affect all residents who consumed food prepared in the facility.
Failure to Follow Planned Menus Due to Untrained Interim Dietary Management
Penalty
Summary
The facility failed to follow its planned and preapproved menus for all residents who consumed food from the facility kitchen. On the specified date, the noon meal served to residents did not match the posted menu; instead of the listed breaded chicken patty on a bun, mini baker potatoes, cream gravy, country trio vegetables, bread with margarine, and flamingo cake, residents received Salisbury steak, au gratin potatoes, country trio vegetables, white gravy, and a cookie. This deviation occurred because the Operations Manager, who was acting as the interim Dietary Manager after the previous manager left, did not order enough food for the planned menus and substituted available items from the facility's storeroom and freezers. The interim Dietary Manager had no training for the role and did not consult with the Registered Dietician regarding these menu changes.
Failure to Ensure Hot Foods Served at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that hot foods were served at a palatable temperature for residents, as required by policy and regulatory standards. Review of the facility's food temperature logs over several weeks revealed numerous instances where food temperatures were not obtained or recorded for breakfast, noon, and evening meals. The facility's policy required that food temperatures be taken and documented for all items prepared in the dietary department, with hot foods maintained at 135°F or higher and reheated foods reaching 165°F. However, logs showed repeated omissions in temperature documentation across multiple days and meals. Direct observations during a noon meal service showed dietary staff removing pre-cooked hot dogs and soup from the refrigerator, reheating them in the microwave, and serving them to residents without checking or recording the food temperatures. During an interview, dietary staff confirmed that temperatures were not obtained or documented for these items and acknowledged that this was a recurring issue, partly due to staffing concerns. This failure had the potential to affect all residents who consumed food from the kitchen.
Delayed Call Light Responses Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by multiple documented instances where residents waited significantly longer than the facility's expected response time of 10 minutes. The facility's Resident Call Light Policy requires staff to respond to call lights as timely as possible and to ensure all residents have access to a functional and responsive call light system. However, review of call light response logs revealed numerous occasions where call lights were left unanswered for periods ranging from over 10 minutes to more than an hour. One resident, who was cognitively intact and dependent on staff for all activities of daily living due to conditions such as quadriplegia and pressure ulcers, experienced repeated delays in call light responses, with several instances exceeding 30 minutes and some over an hour. Another resident with heart failure and dependent on staff for bathing and toileting reported waiting up to 30 minutes for assistance, particularly during evening shifts. A third resident with spina bifida and paraplegia, who required assistance with personal hygiene and dressing, also reported frequent long waits for call light responses, including a documented grievance where the call light was not answered for 56 minutes. This resident indicated that the issue persisted, especially during certain shifts, and that submitting a grievance did not result in any noticeable changes. Interviews with the affected residents confirmed their experiences of delayed responses, with particular concern for insufficient staffing during evening shifts. The administrator acknowledged that the facility's expectation was for call lights to be answered within 10 minutes and confirmed that the documented response times did not meet this standard. There was also a lack of evidence that grievances related to call light response times were investigated or addressed.
Failure to Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of potential staff-to-resident abuse to the State Agency as required by policy and regulation. A resident reported feeling threatened by the Operations Manager (OM), who stated that if the resident did not resolve an outstanding bill, the facility would issue a 30-day notice and, if no alternate placement was found, the OM would take the resident to a homeless shelter with their medications. The resident communicated these concerns to the Social Service Director (SSD), expressing that they felt threatened and did not want to be placed at a homeless shelter. Despite the resident's report and the SSD's acknowledgment that the resident was verbally abused, the SSD did not report the allegation to the State Agency or notify anyone else at the facility. A review of facility investigations over the relevant period showed no evidence that this allegation of verbal abuse was reported as required. The OM confirmed the statements made to the resident regarding discharge and potential placement at a homeless shelter.
Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of potential staff-to-resident verbal abuse as required by policy and state regulations. A resident reported to the Social Service Director (SSD) that they felt threatened by the Operations Manager (OM), who stated that if the resident did not resolve an outstanding bill, the facility would issue a 30-day notice and, if no alternate placement was found, the OM would take the resident to a homeless shelter with their medications. The SSD acknowledged feeling that the resident was verbally abused but did not notify the facility Administrator or initiate an investigation into the allegation. A review of facility records showed no evidence that the allegation was reported to the State Agency or that an investigation was conducted. Interviews confirmed that the OM made the statements to the resident and that the Administrator was unaware of the allegation, resulting in no investigation or report being submitted as required. The facility's policy mandates immediate reporting and investigation of such allegations, but these steps were not followed in this case.
Failure to Label and Date Food Items in Resident Refrigerator
Penalty
Summary
The facility failed to adhere to food safety standards as outlined in the Nebraska Food Code, which is based on the United States Food and Drug Administration Food Code. During an observation conducted on September 30, 2024, it was noted that several food items in the resident refrigerator were not labeled or dated. These items included a juice-like drink in a 24-ounce clear plastic container, two containers with tomatoes, a sandwich in plastic wrap, and a container with peppers, onions, chicken legs, and squash. The lack of labeling and dating of these items is a violation of the food safety standards, specifically the requirement that refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than twenty-four hours must be clearly marked to indicate the date of preparation. The facility's Operations Manager confirmed during an interview on October 2, 2024, that items stored in the kitchen refrigerators should indeed be labeled and dated. This oversight in food storage practices had the potential to affect all residents consuming food from the facility kitchen, given the facility's census of 38 residents. The failure to properly label and date food items could lead to foodborne illnesses, posing a significant risk to resident health and safety.
Failure to Provide Bed Hold Information
Penalty
Summary
The facility failed to provide the required bed hold information to a resident and/or their representative when the resident was transferred to the hospital. According to the facility's Bed Hold policy, revised in December 2023, written information regarding the right to exercise the bed hold provision of 15 days should be provided at admission and again before transferring to a hospital or going on therapeutic leave. In cases of emergency transfer, this information should be given within 24 hours. The information should include the duration of the state bed-hold, the reserve bed payment policy, the facility's policy on bed-hold periods, and the conditions for the resident's return to the facility. A review of the nursing progress notes for a resident revealed that on September 10, 2024, the resident reported difficulty breathing and requested to be evaluated in the emergency room. The resident was admitted to the hospital and later discharged back to the facility on September 12, 2024. However, there was no evidence in the medical record that the resident or their representative was notified of the facility's bed hold policy during this period. The facility's administrator confirmed the lack of documented evidence of providing the required bed hold information during an interview conducted on October 2, 2024.
Failure to Revise Care Plans for Suicidal Ideation
Penalty
Summary
The facility failed to ensure that the care plans for two residents were appropriately revised to address significant mental health concerns. Resident 30, who had intact cognitive functioning and complex medical conditions including hemiplegia, diabetes, hypertension, and vascular disease, expressed suicidal ideation. Despite these expressions, the resident's care plan, last revised on 7/14/24, did not include interventions for the resident's comments of self-harm. The facility's Director of Nursing (DON) confirmed that the care plan did not address the resident's suicidal ideation or the safety interventions that were implemented, such as 15-to-30-minute checks and the use of plastic silverware. Similarly, Resident 35, who was cognitively intact and had diagnoses of depression, spine narrowing, heart disease, and stroke, also expressed thoughts of self-harm. The resident's care plan, last revised on 9/3/24, did not document these thoughts or include interventions to address them. Although a physician fax indicated interventions such as increased staff interaction and encouraging outdoor activities, these were not incorporated into the care plan. The DON confirmed that the care plan did not address the resident's thoughts of self-harm and that the interventions from the fax were not implemented.
Failure to Monitor and Report Bruising on Resident
Penalty
Summary
The facility staff failed to identify and monitor a bruise on Resident 17, who was admitted with diagnoses of stroke, hemiplegia, and anemia, and had severe cognitive impairment. The resident required substantial to maximal assistance with daily activities and was at risk for skin impairment. Despite these risks, the facility's care plan interventions, which included monitoring and reporting changes in skin status, were not followed. Observations revealed a large bruise on the resident's left hand, which was not documented in the Weekly Skin Evaluations, indicating a lapse in monitoring and reporting. Nurse Aide (NA)-B reported the bruise to the Charge Nurse a week prior, but there was no evidence of follow-up or evaluation of causal factors. The Treatment Administration Records, Nursing Progress Notes, and Weekly Skin Evaluations did not reflect the presence of the bruise, nor was there any monitoring to ensure healing. Registered Nurse (RN)-I confirmed that staff were responsible for weekly skin evaluations to identify and monitor new skin issues, but was unaware of the bruise on Resident 17's hand, highlighting a breakdown in communication and procedure adherence.
Failure to Document Stop Date for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's antianxiety medication, Lorazepam, had a documented stop date or duration for use, which is a requirement for PRN orders of psychotropic medications. The facility's policy mandates that PRN orders for psychotropic medications should be limited to 14 days unless the provider documents the rationale and duration for extending the order. However, the review of the Medication Administration Records for August and September 2024 revealed that the Lorazepam order, initiated on August 14, 2024, lacked a stop date or specified duration. The resident involved had severe cognitive impairment and was diagnosed with cancer, seizures, anxiety, depression, and a psychotic disorder. The resident was also receiving hospice services and required assistance with daily activities. Despite these conditions, the facility did not adhere to its policy regarding the administration of psychotropic medications, as confirmed by interviews with the Director of Nursing and the Assistant Director of Nursing. They acknowledged that the PRN order for Lorazepam should have included a stop date, which was not documented in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by observations and interviews. During the survey, 31 medications were observed, resulting in 2 errors, which affected 2 out of 3 residents, leading to an error rate of 6.45%. The facility's policy on administering medications, reviewed in May 2021, requires medications to be administered according to orders and within one hour of the prescribed time. Additionally, the policy mandates that the individual administering the medication must verify the right resident, medication, dosage, time, and route by checking the label three times before administration. The first error involved Resident 25, who had a physician's order for Insulin Glargine 15 units subcutaneously twice a day. The LPN administering the insulin failed to expel 2 units of potential air bubbles from the insulin pen before selecting the ordered dose, as per the manufacturer's instructions. The second error involved Resident 21, who had a physician's order for Pantoprazole 20 milligrams to be administered daily, 30 to 60 minutes before a meal. The RN administered the medication only 9 minutes before the resident was served breakfast, contrary to the physician's order. Both errors were confirmed through interviews with the respective nursing staff.
Infection Control Deficiencies in PPE Use, Equipment Storage, and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, as evidenced by multiple observations of staff not wearing personal protective equipment (PPE) correctly. Specifically, a registered nurse (RN) was repeatedly seen with their mask below their nose and eye protection improperly positioned while interacting with residents and visitors. This was confirmed by interviews with the Infection Preventionist and the Director of Nursing (DON), who acknowledged the improper use of PPE. Additionally, the facility did not follow its policy for the proper storage of respiratory equipment. Observations revealed that Resident 34's oxygen tubing and nasal cannula were left on the floor or improperly stored without a bag, contrary to the facility's policy. Interviews with staff and the resident confirmed that the tubing was not stored in a bag as required, which was also acknowledged by the DON. The facility also failed to maintain proper hand hygiene practices. During care for Resident 23, a certified nursing assistant (CNA) did not change gloves or perform hand hygiene at the required intervals, despite handling soiled items and performing personal care tasks. Furthermore, Resident 30's urinal was repeatedly observed on the overbed table next to food and snacks, which was not in line with the facility's infection control practices, as confirmed by an RN.
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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 Randolph
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park View Haven Nursing Home | 12.2 mi | ★★★★★ | 10 | 0 |
| Hillcrest Care Center | 14.2 mi | — | 0 | 0 |
| Accura Healthcare Of Pierce | 14.6 mi | ★★★★★ | 2 | 0 |
| Accura Healthcare Of Hartington | 17.7 mi | ★★★★★ | 5 | 0 |
| Wayne Countryview Care And Rehabilitation | 20 mi | ★★★★★ | 8 | 0 |
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