Colonial Manor Of Randolph

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on record review and interview; the facility failed to report an allegation of potential staff to resident abuse to the State Agency for 1 (Resident 2) of 4 sampled residents. The facility census was 44. Findings are:A. Review of the facility policy Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment with a reviewed date of 12/2023 revealed

it was the policy of the facility that each resident had the right to be free from abuse, neglect, misappropriation of property, exploitation, and mistreatment. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility would:-ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property were reported immediately but not later than 2 hours after the allegation was made if the events that cause

the allegation involved abuse or resulted in serious bodily injury and not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury.-ensure all alleged allegations were reported to the Administrator of the facility, the State Agency, and Adult Protective Services (APS). B. During an interview on 10/1/25 at 10:40 AM, Resident 2 identified feeling threatened by

the Operations Manager (OM) of the facility. The resident reported being told if the resident did not take steps to resolve an outstanding bill, the facility would give the resident a 30 day notice. The facility would assist Resident 2 with trying to find an alternate facility, but if no one would accept the resident, then the OM would drop the resident with the resident's medications at a homeless shelter. The resident indicated telling the Social Service Director (SSD) about feeling threatened by the OM. Review of facility investigations from 10/3/24 to 10/1/25 revealed no evidence Resident 2's allegation of verbal abuse was reported to the State Agency. An interview with the SSD on 10/2/25 at 9:10 AM confirmed on 8/10/25 at 2:22 PM, the resident notified the SSD the resident had felt threatened by the OM and did not want to be placed at a Homeless Shelter. The SSD indicated feeling the resident was verbally abused. The SSD, however, failed to report this allegation of potential abuse to the State Agency and failed to notify anyone else at the facility about this allegation. During an interview on 10/2/25 at 11:00 AM, the OM confirmed telling Resident 2 if the resident's bill was not resolved, the facility would issue the resident a 30 day notice.

The OM further confirmed if the resident could not find placement with another facility, the OM's plan was to take the resident to a homeless shelter with the resident's medications.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Manor of Randolph

811 South Main Street Randolph, NE 68771

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on record review and interview; the facility failed to investigate an allegation of potential staff to resident abuse and to submit the results of the investigation to the State Agency within the required timeframe for 1 (Resident 2) of 4 sampled residents.

The facility census was 44. Findings are:A. Review of the facility policy Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment with a reviewed date of 12/2023 revealed it was the policy of

the facility that each resident had the right to be free from abuse, neglect, misappropriation of property, exploitation, and mistreatment. In response to allegations of abuse, neglect, exploitation or mistreatment,

the facility would:-ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property were reported immediately but not later than 2 hours after the allegation was made if the events that cause the allegation involved abuse or resulted in serious bodily injury and not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury. -ensure all alleged allegations were reported to the Administrator of the facility, the State Agency, and Adult Protective Services (APS).-ensure that the results of all investigations were reported within 5 working days of the incident to the Administrator and the State Survey Agency. B. During an interview on 10/1/25 at 10:40 AM, Resident 2 identified feeling threatened by the Operations Manager of the facility. The resident reported being told if the resident did not take steps to resolve an outstanding bill, the facility would give the resident a 30 day notice. The facility would assist Resident 2 with trying to find an alternate facility, but if no one would accept the resident, then

the OM would drop the resident with the resident's medications at a homeless shelter. The resident indicated telling the Social Service Director (SSD) about feeling threatened by the OM.Review of facility investigations from 10/3/24 to 10/1/25 revealed no evidence Resident 2's allegation of verbal abuse was reported to the State Agency. An interview with the SSD on 10/2/25 at 9:10 AM confirmed on 8/10/25 at 2:22 PM, the resident notified the SSD the resident had felt threatened by the OM and did not want to be placed at a Homeless Shelter. The SSD indicated feeling the resident was verbally abused. The SSD, however, failed to notify the facility Administrator and to initiate an investigation of the resident's abuse allegation. During an interview on 10/2/25 at 11:00 AM, the OM confirmed telling Resident 2 if the resident's bill was not resolved, the facility would issue the resident a 30 day notice. The OM further confirmed if the resident could not find placement with another facility, the OM's plan was to take the resident to a homeless shelter with the resident's medications. During an interview on 10/2/25 at 12:48 PM the facility Administrator confirmed no investigation was completed and/or submitted to the State Agency regarding Resident 2's allegation of verbal abuse as the Administrator was unaware of the allegation.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Manor of Randolph

811 South Main Street Randolph, NE 68771

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725

-9/7/25 the call light was on from 7:22 PM to 8:11 PM (48 min, 45 sec).

Level of Harm - Minimal harm or potential for actual harm

-9/10/25 the call light was on from 8:02 PM to 8:22 PM (20 min, 38 sec). -9/11/25 the call light was on from 2:48 PM to 3:04 PM (16 min, 17 sec).

Residents Affected - Some -9/11/25 the call light was on from 10:15 PM to 10:31 PM (16 min, 5 sec). -9/12/25 the call light was on from 10:00 AM to 10:13 AM (13 min, 3 sec). -9/12/25 the call light was on from 1:57 PM to 2:14 PM (17 min, 13 sec). -9/12/25 the call light was on from 7:43 PM to 8:09 PM (25 min, 54 sec), -9/14/25 the call light was on from 12:26 PM to 12:37 PM (11 min, 15 sec). -9/24/25 the call light was on from 7:51 PM to 8:35 PM (43 min, 52 sec). -9/25/25 the call light was on from 7:55 PM to 8:15 PM (20 min, 11 sec). -9/26/25 the call light was on from 9:25 AM to 10:00 AM (34 min, 47 sec). -9/26/25 the call light was on from 10:17 AM to 10:31 AM (13 min, 44 sec). -9/26/25 the call light was on from 6:03 PM to 6:50 PM (47 min, 3 sec). -9/27/25 the call light was on from 11:00 AM to 11:10 AM (10 min, 45 sec). -9/27/25 the call light was on from 11:24 PM to 11:43 PM (19 min, 8 sec). -9/28/25 the call light was on from 7:50 PM to 8:06 PM (16 min, 3 sec). -9/29/25 the call light was on from 10:07 AM to 10:19 AM (12 min, 38 sec). -9/29/25 the call light was on from 5:17 PM to 5:47 PM (29 min, 58 sec). -9/29/25 the call light was on from 7:34 PM to 7:49 PM (15 min, 6 sec), and -9/30/25 the call light was on from 8:13 PM to 8:30 PM (16 min, 39 sec).

Interview on 10/2/25 at 2:50 PM with the Administrator confirmed call lights were to be answered within 10 minutes, and further interview confirmed the call lights on the Incident List were not answered within the expected time frame.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Manor of Randolph

811 South Main Street Randolph, NE 68771

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

the facility Dietary schedule for 9/1/25 to 9/30/25 revealed the following:-9/5/25 the OM served as the evening cook.-9/6/25 the OM served as the day shift cook.-9/7/25 the OM served as the day shift and the evening shift cook.-9/13/25 the OM served as the day shift cook. F. An interview on 10/2/25 at 9:30 AM with

the facility OM confirmed the following:-currently worked in the capacity of the interim DM. The previous DM had left last month, and the facility had been unable to hire another DM.-the OM had not had any training related to the DM position or as a cook and had not consulted with the Registered Dietician regarding menu changes.-the facility has struggled with the staffing in the kitchen and the Interdisciplinary Team (IDT) was helping with the Dietary Aide position and had training regarding safe dishwasher temperatures and the completion of the dishwasher temperature logs.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Manor of Randolph

811 South Main Street Randolph, NE 68771

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Licensure Reference: 175 NAC 12-006.11A1 Based on observation, interview, and record review, the facility failed to follow planned menus for all residents who consumed food from the facility kitchen. The facility had a total census of 44 residents.Findings are:Review of the facility Month at a Glance noon meal menu for 10/1/25 revealed the noon meal was listed as breaded chicken patty on a bun, mini baker potatoes, cream gravy, country trio vegetables, bread with margarine and flamingo cake. Observation of the noon meal service on 10/1/25 from 11:45 AM to 1:27 PM revealed the residents were served Salisbury steak, au gratin potatoes, country trio vegetables, white gravy, and a cookie. An interview with Dietary [NAME] (DC)-L on 10/1/25 at 12:09 PM revealed the facility was not following the preapproved/planned menus as the Operations Manager (OM) was ordering the food for the kitchen and had failed to order enough food for the designated menus. DC-L had replaced items on the menu with food that was available

in the facility freezers and storeroom.An interview on 10/2/25 at 9:30 AM with the facility OM confirmed the following-currently worked in the capacity of the interim Dietary Manager (DM). The previous DM had left last month, and the facility had been unable to hire another DM. -the OM had not had any training related to

the DM position or as a cook and had not consulted with the Registered Dietician regarding menu changes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Manor of Randolph

811 South Main Street Randolph, NE 68771

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observations, record review and interviews; the facility failed to ensure that hot foods were served at a palatable temperature for facility residents. This had the potential to affect all 24 residents in the facility that ate food served out of the kitchen. The facility census was 44. Findings are: A. Review of the facility policy Food Temperatures (undated) revealed it was the policy of this facility to take and record food temperatures for each meal to ensure food was served at the proper temperature. The following guidelines were to be followed:-food temperatures were to be recorded on all items prepared in the dietary department.-hot food items were to be maintained at 135 degrees Fahrenheit (F) or higher.-food that was cooked and then cooled was to be reheated so that all parts of the food reached an internal temperature of 165 degrees (F). B. Review of a Food Temperature Log from 8/31/25 to 9/6/25 revealed no evidence food temperatures were obtained and/or recorded for the breakfast, noon, and the evening meals from 8/31/25 to 9/6/25. Review of Food Temperature Log form 9/7/25 to 9/13/25 revealed the following:-breakfast meal no temperatures were documented on 9/7, 9/10, 9/11, 9/12 and on 9/13.-noon meal no temperatures were documented on 9/7, 9/9, 9/10, 9/11, 9/12 and on 9/13.-evening meal no temperatures were documented on 9/8, 9/9, 9/10 and

on 9/13. Review of a Food Temperature Log from 9/14/25 to 9/20/25 revealed the following:-breakfast meal no food temperatures were documented on 9/14, 9/15 and on 9/20.-noon meal no temperatures were documented on 9/14, 9/15, and on 9/20.-evening meal no food temperatures were documented on 9/14, 9/15, 9/16, and on 9/18. Review of a Food Temperature Log from 9/21/25 to 9/27/25 revealed the following:-breakfast meal no food temperatures were documented on 9/21 and on 9/26.-noon meal no temperatures were documented on 9/21 and on 9/26.-evening meal no food temperatures were documented on 9/21, 9/22, and on 9/27. Review of a Food Temperature Log from 9/28/25 to 10/1/25 revealed the following:-breakfast meal no temperatures were documented on 9/29.-noon meal no temperatures were obtained on 9/29.-evening meal no food temperatures were obtained on 9/29 and on 9/30. C. During the service of the noon meal on 10/1/25 from 11:45 AM to 1:27 PM the following was observed:-12:28 PM Dietary [NAME] (DC)-L removed a hot dog stored on a plate from the kitchen refrigerator. DC-L put the plated hot dog into the microwave for 55 seconds and then placed the hot dog into a bun with ketchup. The hot dog was sent out of the kitchen without checking the temperature of the item to ensure palatability before serving.-12:41 PM DC-L placed soup into a bowl from a container which had been stored in the refrigerator. The soup was then placed into the microwave for 1 minute. Without obtaining a temperature of the food item to ensure palatability, the bowl of soup was served out of the kitchen. -12:43 PM DC-L removed another hot dog from the refrigerator, which was already stored on a plate, heated in the microwave for 50 seconds and then placed into a bun with mustard/ketchup. DC-L failed to obtain a temperature of the food item before it was served to the resident. During an interview on 10/1/25 at 12:55 PM, DC-L confirmed the failure to obtain the temperature of the hot dogs and soup served at the noon meal. DC-L further confirmed all food items were to have a temperature obtained and then recorded prior to serving. If a food item had been pre-cooked and then refrigerated, the food should have a reheated temperature of 165 degrees (F) to ensure palatability. In addition, DC-L identified the staff had failed to obtain and/or document food temperatures at meals at times throughout the month of September due to staffing concerns.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet