Randolph Health Services

In the surveyor’s words

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

• Immediate jeopardy, patternF689Dec 18, 2024

  Based 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. […]

• Actual harm, isolatedF686Dec 18, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Dec 18, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Dec 18, 2024

  Based 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. […]