Randolph County Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF689Apr 30, 2024

  Based 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. Findings include: The Immediate Jeopardy began on 2/8/2024 when R21 sustained a second degree burn from spilling hot coffee on himself. On 4/26/2024 at 1:50 PM, V1 (Administrator), V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) were notified of the Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF689Apr 22, 2025

  Based 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. […]

• Actual harm, isolatedF742Apr 22, 2025

  Based 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. Findings includes: 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. […]

• Actual harm, isolatedF742Apr 22, 2025

  Based 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. Findings includes: 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. […]

• Actual harm, isolatedF755May 12, 2022

  Based on interview, observation, and record review, the facility failed to ensure narcotic medication was securely stored, failed to accurately document narcotic medication administration, failed to consistently and accurately reconcile narcotic medication counts in accordance with professional standards of practice; and failed to administer narcotic medication as prescribed for 4 (R1, R2, R3, R5) of 5 residents reviewed for narcotic medication in a sample of 5. This failure resulted in R3 missing four consecutive doses of her narcotic pain medication to treat her diagnosis of chronic pain. A reasonable person would experience symptoms of mild to moderate pain and express feelings of discomfort due to not receiving their scheduled dose of pain medication. […]