A list of the most recent deficiencies for Randolph Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-29 | 2023-11-10 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-08-29 | 2023-10-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-29 | 2023-10-12 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-08-29 | 2023-10-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-29 | 2023-10-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-29 | 2023-10-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-29 | 2023-10-12 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-08-29 | 2023-10-12 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-08-29 | 2023-10-12 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-08-11 | 2023-09-04 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-08-11 | 2023-09-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-11 | 2023-09-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-08-11 | 2023-09-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-11 | 2023-09-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-11 | 2023-09-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-11 | 2023-09-04 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-08-11 | 2023-09-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-11 | 2023-09-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-08-11 | 2023-07-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-06-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-08 | 2023-06-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-20 | 2023-03-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-20 | 2023-03-24 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-23 | 2022-09-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-19 | 2021-11-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-19 | 2021-11-08 | Y |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-06 | 2021-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-30 | 2021-05-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-04-30 | 2021-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-30 | 2021-05-24 | N |
