Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Randolph Health Services during CMS and state inspections, most recent first.
Dishwashing was not completed in accordance with food service safety standards. A Dietary Aide was observed running the high-temp dishwasher without any observed pre-use temperature checks, and the aide stated the machine was only checked at the end of dishwashing. In a separate observation, a Dietary Aide stacked two wet pans on top of other pans, and the RDM confirmed that wet-stacking is not allowed and dishes must be dry before stacking.
A resident with a scalp surgical wound after a Mohs procedure had orders for daily wound care, including washing the site and applying Vaseline, but the TAR only showed the treatment on Tuesdays and Fridays. An RN confirmed the care was being completed only on those two days, and the DON stated the order had been entered incorrectly and the facility should have been doing the wound care daily.
A resident with an indwelling urinary catheter, diagnoses including UTI and obstructive/reflux uropathy, was observed twice with the drainage bag uncovered and resting on the floor. CNAs confirmed the bag should not be on the floor, and the DON stated catheter bags need to be covered and cannot be on the floor.
A resident with cognitive impairment reported missing money and a coin purse from his room. The facility conducted an internal investigation and reported the incident to the State agency, but did not notify local law enforcement, despite facility policy requiring such reporting for suspected misappropriation. The administrator cited the resident's and power of attorney's wishes and uncertainty about reporting thresholds, but acknowledged that coordination with law enforcement had not occurred as required.
A cognitively impaired resident fell onto a heat register, sustaining severe burns due to the facility's failure to maintain beds at a safe distance from heat sources. Despite having a policy in place, staff did not consistently follow it, and there was no system to monitor heat register temperatures. Surveyors found multiple residents in similar hazardous conditions, indicating a pattern of non-compliance.
A resident developed a stage 3 pressure injury due to the facility's failure to adhere to a repositioning schedule and implement prescribed wound care treatments. The resident, with limited mobility and at risk for skin integrity issues, was not repositioned every 2 hours as required, and the treatment plan was not fully executed. Staff interviews revealed a lack of awareness and documentation regarding the resident's condition.
The facility failed to maintain a sanitary environment for food preparation, with dust-covered stove hoods and expired milk being served. The Dietary Manager was unsure of cleaning responsibilities, and dented cans were found in circulation, violating food safety protocols.
The facility failed to maintain an effective infection control program, as evidenced by incomplete resident infection line lists and an inaccurate COVID-19 outbreak summary. The line lists did not include residents with symptoms but no antibiotic orders, and the outbreak summary omitted a resident and lacked documentation of audits and testing. Additionally, an LPN was observed placing a contaminated nasal cannula back into use, highlighting a breach in infection control protocols.
A resident with poor vision, due to vascular dementia and eye conditions, was not provided with a glass plate as per her preference, affecting her ability to place her glass without spilling. The facility used Styrofoam plates despite having enough glass plates, and the resident's preference was not documented on her diet slip.
A resident with multiple health conditions was found with a significant bruise on the right eye, which was not reported to the State Agency as required. Despite an investigation by the facility, the cause of the bruise remained unknown. The facility's policy requires reporting such injuries within specific timeframes, but the DON decided against reporting after the investigation.
A resident with a bruise to the right eye did not receive a thorough investigation by the facility. Despite the facility's policy requiring comprehensive investigation, only limited staff interviews were conducted, and no definitive cause for the bruise was determined. The DON suggested possible causes but did not pursue further investigation.
Two residents receiving Melatonin for sleep did not have comprehensive sleep assessments, sleep tracking, or care plans in place. Despite having physician orders for Melatonin, the facility failed to document sleep assessments or include sleep-related goals and interventions in the care plans. The DON acknowledged the expectation for such assessments and plans for residents on sleep medications.
A resident with PTSD, anxiety, and depression did not receive appropriate treatment and services due to a non-individualized care plan. The care plan lacked specific details about the resident's trauma, triggers, and effective interventions, despite recommendations for a private room to avoid triggering events. Interviews revealed the resident's history of military trauma, including a sexual assault, but these were not adequately addressed in the care plan.
Dishwashing temperatures not checked before use and wet dishes were stacked
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During observation, a Dietary Aide performed dishwashing without any observed testing of the high-temperature dishwasher before beginning the process. When asked about pre-use temperature checks, the Dietary Aide stated that the temperature was checked on the yellow disk at the end of dishwashing and did not know whether the water temperature at the start of dishwashing was known to ensure dishes were sanitized. The Regional District Manager also stated they did not know whether dishes could be confirmed as sanitized if temperatures were not tested prior to dishwashing and said they may need to start doing temperatures before the start of dishwashing. In a separate observation, a Dietary Aide removed two pans from the dishwasher and placed them together on top of other pans while they were still wet. When asked, the Dietary Aide confirmed the pans were wet and stated dishes should be dry before stacking because wet stacking could cause mold. The Regional District Manager later stated that wet-stacking of dishes is not allowed and that dishes need to be dry before stacking.
Inconsistent wound care order entry and missed daily treatment
Penalty
Summary
R26, a cognitively intact resident with a history of skin cancer, had a surgical wound on the right side of the scalp after a Mohs procedure with exposed bone noted on observation. The dermatology order dated 2/9/26 directed daily wound care to wash the site, apply Vaseline to the entire wound, and continue care until new tissue filled in and the area healed. The physician orders for February and March 2026 also directed daily cleaning of drainage around the wound with water and a soft cloth, cleaning the wound bed and edges with tap water two times a week, applying a large amount of Vaseline every day, and keeping the wound covered when showering. The Treatment Administration Record only displayed the wound care on Tuesdays and Fridays, and the treatment was signed as completed only on those days. An RN reviewed the TAR and order and stated the wound care was being completed only on Tuesdays and Fridays, while the DON stated the order had been entered incorrectly and should have been entered as daily. The DON also stated the facility should have been completing the wound care daily and was not.
Uncovered catheter drainage bag left on the floor
Penalty
Summary
The facility did not ensure appropriate catheter care and services to prevent infections or complications for a resident with an indwelling urinary catheter. The resident had diagnoses including urinary tract infection and obstructive and reflux uropathy, and the care plan directed that the catheter collection bag be placed in a dignity bag holder on the bed or wheelchair. The facility’s catheter care policy stated that privacy/dignity bags should be available and catheter drainage bags should be covered or shielded at all times while in use. Surveyors observed the resident lying in bed with the urinary drainage bag uncovered and resting on the floor on two separate occasions. During both observations, CNAs confirmed the bag was on the floor and stated it should not be there and should be in a bag or basin. The DON also stated that catheter bags need to be covered and cannot be on the floor.
Failure to Report Suspected Misappropriation of Resident Funds to Law Enforcement
Penalty
Summary
The facility failed to ensure that all alleged violations involving misappropriation of resident funds or personal property were reported immediately to the administrator, the State agency, and local law enforcement, as required by facility policy and federal regulations. In the case reviewed, a resident with significant cognitive impairment, including hemiplegia, hemiparesis, aphasia, and a low BIMS score, reported missing monetary funds from his room. The amounts reported missing varied during interviews, ranging from $38 to $80, and the resident also mentioned a missing coin purse. The facility conducted a search of the resident's room, interviewed the resident and his activated power of attorney, and reviewed the resident's account activity, but was unable to determine if the funds were ever in the resident's possession or if they had been taken. Despite the facility's internal investigation and reporting to the State agency, the incident was not reported to local law enforcement. The administrator and social services director did not contact law enforcement, citing the resident's and power of attorney's wishes not to involve police and uncertainty about the threshold for reporting theft. The administrator acknowledged during interviews that stealing is a crime and that facility policy requires coordination with law enforcement to determine what constitutes a reportable crime, but also admitted that such coordination had never occurred and that she did not need permission from the resident or family to follow abuse reporting procedures. The facility's failure to report the suspected misappropriation of resident funds to local law enforcement was contrary to its own written policies and federal requirements. The policies specify that all alleged violations involving misappropriation must be reported to law enforcement within specified timeframes, regardless of the amount involved or the wishes of the resident or their representative. The administrator's decision not to report the incident denied the resident the resource of law enforcement involvement and did not comply with established procedures for reporting suspected crimes in the facility.
Failure to Maintain Safe Environment Leads to Resident Burns
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, leading to a serious incident involving a cognitively impaired resident, R56. R56 fell out of bed and onto a heat register, sustaining second- and third-degree burns. The facility had a policy requiring beds to be at least 18 inches away from heat registers, but this policy was not consistently followed. Surveyors observed multiple residents, including R56, in beds positioned closer than the required distance to heat registers, indicating a pattern of non-compliance with safety protocols. The incident with R56 highlighted the facility's failure to implement a system for monitoring the surface temperature of heat registers, which contributed to the severity of the burns sustained by the resident. Despite the facility's policy, staff did not consistently maintain the required distance between beds and heat registers, as evidenced by surveyors' observations of other residents in similar situations. The lack of monitoring and adherence to safety protocols created an environment where serious harm was likely to occur. Interviews with staff and observations by surveyors revealed that beds were often moved closer to heat registers during care activities and not repositioned afterward. This oversight, combined with the absence of a system to monitor heat register temperatures, resulted in a finding of immediate jeopardy. The facility's inaction in maintaining a safe environment and ensuring compliance with its own safety policies directly contributed to the hazardous conditions observed by surveyors.
Removal Plan
- Environmental rounds were completed by the ED/designee to ensure no bed was in close proximity to heating unit.
- In consultation with the DON, rooms were rearranged if necessary.
- One resident with immobility and obesity issues was relocated to a private room to allow for larger safety perimeter between bed and heating unit. Resident's care plan was updated to reflect rationale for private room.
- One resident with obesity and multiple co-morbidities bed was moved out further to allow for a larger safety perimeter between bed and heating unit. Resident's care plan was updated to reflect rationale for this.
- ED/designee to complete environmental rounds/audits daily then 3x per week through the remainder of the heating season to ensure beds/chairs/furniture not close to heating units where a resident's skin could come in contact.
- Results of rounds/audits will be brought to QAPI for tracking/trending and further recommendations, as necessary and appropriate.
- Discussion regarding noted concern and removal plan reviewed with Medical Director and ad hoc QAPI meeting held.
- Re-education initiated with center staff (including PRN and agency staff if applicable) to reinforce that anytime the side of a bed is noted to be too close to a heater/heating unit (where a resident's skin could come in contact with the unit), to move it away and to alert the ED/DON for follow up.
- If bed needs to be moved to accomplish cares, be sure to move bed back away from the heater upon completion of cares.
- This re-education will be completed by the DON/designee and will be completed prior to the next scheduled shift.
- ED/VPS, DON, and Maintenance Director reviewed policy Accidents and Supervision.
- Policy meets current standard of practice.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to prevent the development of pressure injuries in a resident who was admitted without any such injuries. The resident, identified as R22, developed a stage 3 pressure injury on the coccyx due to the facility's failure to implement and adhere to a turning and repositioning schedule. The documentation showed that the resident was not repositioned every 2 hours as required, with several instances of non-compliance noted in the repositioning tracker. Additionally, the facility's staff did not accurately document the repositioning activities, leading to prolonged periods without repositioning. The resident, R22, was admitted with diagnoses including heart failure, chronic kidney disease, and peripheral vascular disease, and was dependent on staff for various activities of daily living. Despite being at risk for skin integrity issues due to limited mobility, the facility did not ensure consistent repositioning or adherence to the care plan interventions. The care plan included the use of an air mattress, barrier cream, and frequent repositioning, but these measures were not effectively implemented or documented. Furthermore, the facility failed to implement the wound care treatment orders prescribed by the physician. The treatment plan included the use of leptospermum honey, which was not added to the resident's treatment orders and therefore not performed. The facility also did not conduct a thorough assessment or documentation of the pressure injury's characteristics, leading to inadequate wound management. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition, contributing to the deficiency in care.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 58 residents. The surveyor observed several deficiencies, including dust-covered sprinklers and fixtures inside and outside the stove hood, which were located directly above food being prepared. The Dietary Manager was unsure who was responsible for cleaning these areas, and the District Food Service Manager indicated that the stove hoods are cleaned only twice a year, with maintenance supposed to clean them in between. This lack of regular cleaning could lead to dust dislodging and contaminating food. Additionally, the facility did not adhere to its policy regarding the storage and use of milk, as evidenced by opened gallons of milk without open dates and past their expiration dates being served to residents. The Dietary Manager acknowledged that expired milk was served at breakfast. Furthermore, the surveyor found dented cans in circulation, which should have been removed according to the facility's policy. The District Food Service Manager confirmed that dented cans should be pulled off the shelf, indicating a lapse in following established food safety protocols.
Inadequate Infection Control Program and COVID-19 Outbreak Management
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. The facility did not maintain a comprehensive resident infection control line list, which should include residents displaying signs and symptoms of potential infection. Instead, the line lists for September, October, and November 2024 only included residents on antibiotics, without noting those with symptoms but no antibiotic orders. This lack of comprehensive surveillance was acknowledged by the Director of Nursing (DON) and the Infection Preventionist (IP), who admitted that the line lists did not reflect overall surveillance of residents' signs and symptoms of infection. Additionally, the facility's COVID-19 outbreak summary for March 2024 was incomplete and inaccurate. The summary failed to include all residents with COVID-19 infections, as one resident was omitted from the report. Furthermore, the summary lacked documentation of infection control audits, testing of residents and staff with close contact to COVID-positive individuals, and updates to the medical director or public health authorities. The DON confirmed that the summary should have been complete and accurate, but no additional documentation was provided to the surveyor. A specific breach in infection control was observed during a medication administration when an LPN picked up a resident's nasal cannula from the floor and placed it back into the bag on the portable oxygen tank. The LPN acknowledged that the nasal cannula was contaminated and should not have been on the floor. Both the IP and DON confirmed that a contaminated nasal cannula should be discarded and replaced, indicating a failure to adhere to proper infection control protocols.
Failure to Accommodate Resident's Preference for Glass Plate
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, which affected the resident's quality of life. The resident, who has vascular dementia, glaucoma, and age-related macular degeneration, reported to the surveyor that she relies on clinking her glass against a plate to know where to set it due to her poor vision. However, she was unable to do so because the facility provided her with a Styrofoam plate instead of a glass one. This action did not accommodate her needs and preferences, as outlined in the facility's policy on resident rights. During the survey, it was observed that the resident was served dessert on a Styrofoam plate, despite her preference for a glass plate. The dietary aide mentioned that Styrofoam plates were used to ensure enough glass plates were available for the hall carts. The dietary manager confirmed that the resident had poor vision and that dietary staff were aware of this, but the resident's preference for a glass plate was not listed on her diet slip. The dietary manager also stated that there were enough glass plates for all residents, indicating that the resident's preference could have been accommodated.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident, identified as R22, to the State Agency as required by regulations. R22, who was admitted with diagnoses including heart failure, chronic kidney disease, and peripheral vascular disease, was found to have a significant bruise on his right eye. The bruise was observed by a surveyor during an interview with R22, who was mildly cognitively impaired and dependent on staff for various activities. Despite the facility's investigation, which included interviews with CNAs and nurses, the cause of the bruise remained undetermined, and it was not reported to the State Agency. The facility's policy mandates that any alleged violations involving abuse or injuries of unknown origin be reported immediately, or within 24 hours if they do not involve abuse or serious bodily injury. However, the Director of Nursing (DON) decided not to report the bruise after completing the investigation, believing it did not need to be reported. This decision was made despite the initial classification of the bruise as an injury of unknown origin, which should have triggered a report to the State Agency within the specified timeframe.
Inadequate Investigation of Resident's Bruise
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged violation involving a resident who was found with a significant bruise to his right eye. The resident, who has a history of heart failure, chronic kidney disease, and peripheral vascular disease, was noted to have a bruise that he could not explain. The facility's investigation was limited to interviews with two CNAs and two nurses, none of whom could definitively explain the cause of the bruise. The Director of Nursing (DON) suggested possible causes such as the resident's long fingernails or severe coughing episodes but did not pursue further investigation. The facility's policy requires a comprehensive investigation, including interviews with all involved persons and documentation of findings. However, the facility did not interview staff from previous shifts or other residents, and the investigation lacked thoroughness. The DON acknowledged that the bruise was initially considered an injury of unknown origin but did not follow through with a complete investigation as required by the facility's policy.
Failure to Conduct Sleep Assessments for Residents on Melatonin
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents who were receiving Melatonin for sleep. Both residents, identified as R26 and R23, did not have a comprehensive sleep assessment, sleep tracking, or a sleep care plan in place. R26, who was admitted with diagnoses including anxiety disorder, vascular dementia, and bipolar disorder, had a physician's order for Melatonin 10mg at bedtime for insomnia related to bipolar disorder. However, R26's care plan lacked any problem, goal, or interventions related to sleep, and the facility could not provide documentation of a sleep assessment or monitoring. The Director of Nursing (DON) acknowledged that a comprehensive sleep assessment and care plan should be in place for residents on sleep medications, including over-the-counter medications like Melatonin. Similarly, R23, who was admitted with diagnoses such as generalized anxiety disorder, insomnia, PTSD, and vascular dementia, was also receiving Melatonin 10mg at bedtime for insomnia. Despite having an intact cognition as indicated by a BIMS score of 14 out of 15, R23's medical record did not contain a comprehensive sleep assessment or sleep tracking. Additionally, R23's care plan did not include goals or interventions related to the use of Melatonin, creating a positive sleep environment, or monitoring for sleep. The DON confirmed that she would expect a comprehensive sleep assessment, a completed care plan about sleep, and sleep monitoring for residents on Melatonin.
Inadequate PTSD Care Planning for Resident
Penalty
Summary
The facility failed to ensure that a resident diagnosed with PTSD received appropriate treatment and services to address his condition. The resident, who has a history of trauma from military service, including a sexual assault, was admitted with diagnoses of PTSD, anxiety disorder, major depressive disorder, and hemiplegia following a stroke. Despite these conditions, the resident's care plan was not person-centered and lacked specific details about his trauma, triggers, symptoms to monitor, and effective interventions. The care plan did not specify individualized de-escalation preferences or coping techniques, which are crucial for managing PTSD effectively. During interviews, the resident reported experiencing flashbacks and nightmares related to his military service in Vietnam but was unaware of specific triggers. The Social Services Director confirmed that the psychiatrist identified a sexual assault in the military as a source of the resident's PTSD and recommended a private room to avoid triggering events. However, the care plan did not reflect these findings or recommendations, indicating a lack of individualized care planning for the resident's mental health needs.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Hillside Manor | 10.8 mi | ★★★★★ | 9 | 0 |
| Beaver Dam Health Care Center | 10.8 mi | ★★★★★ | 23 | 2 |
| Markesan Resident Home | 12.8 mi | ★★★★★ | 4 | 0 |
| Columbus Health And Rehab | 13.9 mi | ★★★★★ | 11 | 0 |
| Complete Care At Christian Home Llc | 14.1 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.