Care One at Randolph

In the surveyor’s words

From the most serious findings on record at Care One at Randolph, in the surveyor’s own words.

• Actual harm, isolatedF688May 24, 2023

  Based on observation, interview, and record review, the facility failed to monitor and prevent a left knee contracture from developing after resident completed the initial course of physical therapy for one Resident (#106), out of a total sample of 28 residents. Findings include: Resident #106 was admitted to the facility in October 2022 with a diagnosis of stroke with hemiplegia (paralysis) of the left side. The Resident's Health Care Proxy (HCP) was activated on 11/5/22. Review of the Minimum Data Set (MDS) assessment, dated 4/25/23, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated the Resident had moderate cognitive impairment. Section G0400 Functional limitation in range of motion for the lower extremity: No impairment. […]

• Actual harm, isolatedF760Mar 6, 2023

  Based on records reviewed and interviews for one of five sampled residents (Resident #1), whose physicians orders included Creon (Pancrelipase, prescription medication used to treat people who cannot digest food normally because their pancreas does not make enough enzymes), the Facility failed to ensure he/she was free from a significant medication error, when on 2/18/23, 2/19/23, and 2/20/23, although nursing documented that Resident #1 was administered Creon, the medication was unavailable and not delivered to the Facility until 2/21/23, and could not have been administered. […]

• No harm, potential for more than minimal, widespreadF925Dec 4, 2024

  Based on records reviewed, interviews and for two of three unit kitchenettes, the facility failed to ensure they maintained a pest free environment, when live and dead cockroaches were observed during an environmental tour on the units. Findings include: Review of the Facility's Policy, titled Pest Control, dated as revised May 2008, indicated the Facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Review of the Pest Control Site Inspection Report, dated 11/01/24, indicated that there were cockroaches: -on monitors (location not specified); -behind the freezer (location not specified); -by the cart storage area (location not specified). […]

• No harm, potential for more than minimal, widespreadF812May 24, 2023

  Based on observation and interview, the facility failed to ensure the nourishment kitchenettes were maintained in a clean sanitary manner to prevent potential foodborne illness for 4 out of 4 nourishment kitchenettes. Findings include: On 5/22/2023 at 3:37 P.M., the surveyor toured the four kitchenettes and made the following observations: 3 East Unit nourishment kitchenette: -Shelves that stored the bottles of juices and soda was sticky with a thick layer gelled type of liquid. -Styrofoam take out container on top of the microwave, not labeled or dated. -Floor was sticky with visible food particles and dirt. 3 [NAME] Unit nourishment kitchenette: -Beside the refrigerator was a sticky pest trap with a cockroache and sugar pack stuck to it and paper trash. […]

• No harm, potential for more than minimal, patternF565Aug 14, 2025

  Based on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.Findings include: Review of the facility's policy titled Resident Council, last revised February 2021, indicated but was not limited to the following:-The purpose of the Resident Council is to provide a forum for: -residents, families and resident representatives to have input in the operation of the facility; -discussion of concerns and suggestions for improvement; -consensus building and communication between residents and facility staff; and… […]