CMS Inspection Results for RANDOLPH HEALTH AND REHABILITATION CENTER

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 10/14/2008 Fire Safety Survey for RANDOLPH HEALTH AND REHABILITATION CENTER

Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm

 

• 09/27/2008 Health Survey for RANDOLPH HEALTH AND REHABILITATION CENTER

Administration
Deficiency	Scope	Level of Harm
Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
Give professional services that follow each resident's written care plan.	Pattern	Potential for minimal harm
Resident Rights
Deficiency	Scope	Level of Harm
Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Pattern	Minimal harm or potential for actual harm
Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Potential for minimal harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Pattern	Potential for minimal harm

 

• 10/31/2007 Fire Safety Survey for RANDOLPH HEALTH AND REHABILITATION CENTER

Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm

 

• 10/04/2007 Health Survey for RANDOLPH HEALTH AND REHABILITATION CENTER

Pharmacy Service
Deficiency	Scope	Level of Harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Potential for minimal harm

 

• 12/19/2006 Fire Safety Survey for RANDOLPH HEALTH AND REHABILITATION CENTER

Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
restrictions on the use of flammable curtains.	Isolated	Minimal harm or potential for actual harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm

 

• 11/16/2006 Health Survey for RANDOLPH HEALTH AND REHABILITATION CENTER

Environmental
Deficiency	Scope	Level of Harm
Put firmly secured handrails on each side of hallways.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
Provide activities to meet the needs of each resident.	Pattern	Potential for minimal harm
Resident Rights
Deficiency	Scope	Level of Harm
Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Potential for minimal harm
Honor all of the resident's rights as a resident of the nursing home and as a citizen or resident of the United States.	Pattern	Potential for minimal harm