Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Randolph County Care Center during CMS and state inspections, most recent first.
A resident with dementia and multiple health conditions eloped from the facility by removing his monitoring device and using a posted door code to exit. Staff only became aware after the alarm sounded, and the resident was found by police over a mile away with a minor injury. Despite the incident, staff reported no new interventions or changes to the care plan, and the door code remained visible. The facility was short-staffed, especially during evenings and weekends, and staff could not monitor the front entrance due to closed doors and lack of assigned personnel.
A resident with depression and dementia repeatedly expressed suicidal ideation and distress, but the facility failed to develop an individualized care plan addressing these issues, did not consistently document physician notification or follow-up, and did not ensure timely psychiatric evaluation, resulting in harm.
The facility did not include the DON as a member of the QAA Committee, as required by policy and regulation. The most recent QAA meeting was attended by the Administrator, Medical Director, Pharmacist, Medical Records consultant, and ADON, but not the DON, and the Administrator confirmed there is currently no DON. This deficiency could impact all 46 residents.
The facility did not ensure CNAs completed the required 12 hours of annual education, including dementia care and abuse prevention training. Only three in-services were documented in the past year, and there was no tracking of training hours or content. Several CNAs did not receive the necessary training, and the facility lacked a policy and centralized records for required CNA education.
A resident with depression and dementia expressed suicidal ideation, but the facility failed to notify the POA or family as required by policy. Although the physician was informed, there was no documentation of family notification, and the care plan did not reflect the resident's depression diagnosis. The social worker was unavailable to interview the resident on the day of the incident, and both the ADON and social worker acknowledged the lapse in communication.
A resident with Alzheimer's dementia eloped from the facility when only one CNA was present on the floor, as other staff were on break or assigned elsewhere. The resident was found a mile away with injuries after staff were unable to complete required checks due to insufficient staffing. Staff and family interviews confirmed ongoing concerns about inadequate staffing and supervision, especially for residents with high needs.
A resident with multiple sclerosis and other conditions sustained a second-degree burn from spilled hot coffee served at temperatures ranging from 158.5 to 180 degrees Fahrenheit. The facility's policy recommended serving coffee between 135 to 145 degrees Fahrenheit. Despite complaints and staff acknowledgment of the hot coffee, no immediate actions were taken to address the hazard until the incident occurred.
The facility failed to protect two residents from abuse. One resident received a threatening message on his whiteboard, and no investigation report was found. Another resident experienced verbal abuse from a staff member, who was later terminated. Both incidents highlight deficiencies in handling abuse allegations and resident protection.
The facility failed to thoroughly investigate and document an abuse allegation involving a resident's whiteboard message. Despite initial reporting, no final report or documentation of interviews and observations was provided. The family member expressed concerns about the lack of resolution and transparency.
Failure to Prevent Elopement of Resident with Dementia
Penalty
Summary
A deficiency occurred when a resident with dementia and multiple comorbidities, including Parkinson's disease, diabetes, and chronic kidney disease, eloped from the facility without staff knowledge. The resident was known to be at risk for elopement, as documented in his care plan, which included interventions such as daily checks of his monitoring device, 15-minute location monitoring, and documentation of wandering behavior. Despite these interventions, the resident was able to remove his monitoring bracelet using an emery board and exited the facility by entering the door code, which was posted in plain sight above the keypad. Staff became aware of the resident's absence only after the wander guard alarm sounded at the front door. A head count and room checks were conducted, and the monitoring device was found discarded in a trash can near the exit. The resident was located by police approximately one mile away from the facility, sitting in a ditch along a busy road, and was returned to the facility with a minor laceration. Interviews with staff revealed that no new interventions had been implemented following the incident, and the door code remained posted above the keypad. Multiple staff members, including CNAs and LPNs, were unaware of any changes to the care plan or additional precautions to prevent further elopement. Further observations indicated that the facility was short-staffed, particularly during evening shifts and weekends, with no staff assigned to monitor the front entrance after office hours. The double doors leading to the front lobby were kept closed, preventing floor staff from observing the front door. The resident continued to express intentions to leave the facility and demonstrated ongoing exit-seeking behavior. The surveyor team was unable to validate the facility's abatement plan, and the Immediate Jeopardy was not removed at the time of the survey exit.
Failure to Implement Individualized Behavioral Health Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure and implement an individualized plan of care for a resident experiencing psychosocial adjustment difficulties, resulting in harm. The resident, who had diagnoses of depression and dementia and was cognitively intact, expressed frequent feelings of depression and hopelessness, as documented in the Minimum Data Set. Despite these symptoms, the resident's care plan did not address his depression diagnosis, and there was no documentation of a psychiatric evaluation being ordered in the physician's orders. The resident repeatedly voiced thoughts of self-harm and a desire to leave the facility, with specific statements about wanting to end his life if he had to remain in the facility. Progress notes revealed multiple instances where the resident expressed suicidal ideation and distress, including statements about self-harm and feeling like a burden. Staff documented removing potentially harmful objects from the resident's room and noted ongoing behavioral monitoring, but there was a lack of consistent documentation regarding physician notification and follow-up on self-harm statements. The physician stated that an order for a psychiatric evaluation was faxed to the facility, but the administrator and staff were unaware of this order, and it was not present in the resident's chart. The social worker did not interview the resident on the day of a self-harm statement due to being out of the facility, and no documentation was made by the social worker for that incident. Interviews with staff indicated inconsistent understanding and implementation of procedures for addressing self-harm statements. The assistant director of nursing and social worker described protocols for assessment and notification, but these were not consistently followed or documented. The resident continued to display signs of distress, including tearfulness, refusal of care, and statements of wanting to leave or harm himself, without evidence of a comprehensive, individualized behavioral health plan or timely psychiatric intervention.
QAA Committee Lacked Required DON Member
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) was a member of the Quality Assessment and Assurance (QAA) Committee, as required by both facility policy and federal guidelines. Review of the QAA Committee attendance sheet for the most recent meeting showed that the attendees included the Administrator, Medical Director, Pharmacist, Medical Records consultant, and Assistant Director of Nursing (ADON), but not the DON. During an interview, the Administrator confirmed that the facility currently does not have a DON. The facility's QAPI policy specifies that the QAA Committee must include the DON, among other required members. This deficiency has the potential to affect all 46 residents currently residing in the facility.
Failure to Provide Required CNA Training and Education
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) completed the required 12 hours of education per year, including mandatory dementia care and abuse prevention training. The administrator confirmed that only three in-services were provided to CNAs in the past year, covering sexual harassment, resident rights and abuse, and emergency preparedness. There was no documentation of the duration of these in-services, and the facility did not track the total hours of education or the specific content to ensure compliance with training requirements. Additionally, the facility did not provide any dementia care training to CNAs in the past year. Record review showed that several CNAs, including those hired over the past year, only attended the three documented in-services and did not receive the required 12 hours of continuing education or dementia care training. The administrator also stated that the facility does not have a policy on required CNA trainings and does not maintain centralized records to track in-service hours or content. At the time of the survey, the facility had 46 residents who could potentially be affected by this deficiency.
Failure to Notify POA/Family of Resident's Self-Harm Statements
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) or family of a resident who expressed self-harm thoughts. The resident, who had diagnoses of depression and dementia and was documented as cognitively intact, reported feeling upset about his situation and made statements indicating suicidal ideation. Documentation showed that the physician was notified, but there was no evidence in the progress notes that the POA or family was informed of the resident's self-harm statements. The resident's care plan did not reflect his depression diagnosis, and the social worker did not interview the resident on the day of the incident due to being out of the facility. Both the Assistant Director of Nursing (ADON) and the social worker indicated that notifying the family would typically be part of the process, but this was not done in this case. Interviews with the resident's POA/wife confirmed she was not made aware of the resident's self-harm statements at the time, only learning about it later and subsequently taking steps to remove firearms from the home. The facility's policy requires immediate notification of family or POA by telephone in the event of any incident or significant change in condition, with documentation of each attempt in the nurse's notes. However, there was no documentation that the family or POA was notified as required by policy.
Failure to Provide Adequate Staffing Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the supervision needs of a resident with Alzheimer's dementia, resulting in the resident eloping from the facility. On the day of the incident, staffing records show that only one CNA was present on the first floor at times between 4 PM and 5 PM, as another CNA was on a lunch break, the agency LPN was on break outside the facility, and the float CNA was working on the second floor. During this period, the resident eloped, and the wander guard alarm at the front door was triggered. Staff conducted a head count and room checks but were unable to locate the resident, eventually finding the resident's monitoring device discarded in a trash can by the front door. The resident was found approximately a mile away from the facility in a ditch along a busy road, with grass-stained and wet clothing and a cut on his arm, indicating he had fallen during the elopement. Interviews with staff and the resident's wife revealed that the facility was short-staffed, particularly on the evening shift and weekends, and that staff were unable to complete required 15-minute checks for the resident due to insufficient staffing. The resident's wife reported being told by staff that the facility did not have enough help to provide one-on-one supervision or close monitoring for the resident, and she felt pressured to take him home for the weekend as a result. Staff statements confirmed that breaks were taken simultaneously by key personnel, leaving only one CNA on the floor during a critical period. The administrator acknowledged that there was no formal staffing policy and was unaware that both the agency nurse and a CNA were on break at the same time. Multiple staff members expressed concerns about inadequate staffing levels and the challenges of supervising residents with high needs, such as those at risk for falls or elopement, when staffing was insufficient.
Resident Burn Incident Due to Unsafe Coffee Temperatures
Penalty
Summary
The facility failed to ensure the safety of residents by serving coffee at unsafe temperatures, leading to an Immediate Jeopardy situation when a resident, R21, sustained a second-degree burn from spilled hot coffee. R21, diagnosed with multiple sclerosis, pneumonia, bacteremia, urinary tract infection, and other conditions, was cognitively intact for decision making according to the Minimum Data Set. Despite R21's limited physical mobility, the facility continued to provide hot coffee to residents without adequate precautions. Observations on April 25, 2024, revealed that the coffee served to residents was excessively hot, with temperatures ranging from 158.5 to 180 degrees Fahrenheit. Staff members acknowledged the hot temperature of the coffee, with one resident mentioning that they usually put silverware in their coffee to cool it down. The facility's Precautions for Hot Beverages Policy recommended serving temperatures between 135 to 145 degrees Fahrenheit to prevent burns, highlighting a significant deviation from safe practices in this case. The facility's Dietary Manager received complaints about the hot coffee but was not aware of any injuries until R21's second-degree burn incident. Despite the acknowledgment of the hot coffee temperatures by staff and residents, no immediate actions were taken to address the hazard until the Immediate Jeopardy situation was identified. The failure to monitor and control the temperature of the coffee served to residents directly contributed to the unsafe environment and the subsequent burn incident experienced by R21.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure abuse did not occur for two residents, R9 and R149, as documented in the report. R149, who had multiple medical conditions including acute cholecystitis, pneumonia, and severe cognitive impairment, was found to have a threatening message written on his whiteboard, warning him to stop abusing the call light. Despite the family reporting this to the administrator, no final investigation report was found, and staff members were unable to provide any information about the incident or the staff member involved. The resident's family expressed concern about the lack of resolution and the potential ongoing risk to other residents. In the case of R9, the facility reported an incident where a staff member raised her voice and used a curse word while providing care. The resident, who had diagnoses including congestive heart failure and major depressive disorder, reported that the staff member yelled at him when he requested not to be left on the bedpan for an extended period. Another staff member corroborated the resident's account, stating that the staff member called the resident a derogatory term. The staff member involved was suspended and subsequently terminated, but the incident highlighted a failure to protect the resident from verbal abuse. Both incidents demonstrate a failure by the facility to protect residents from abuse and to conduct thorough investigations into reported abuse. The lack of documentation and follow-up in R149's case, and the verbal abuse experienced by R9, indicate significant deficiencies in the facility's handling of abuse allegations and resident protection protocols.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure all abuse allegations were thoroughly investigated and completed for one resident reviewed for abuse. The initial investigation report documented a family member's concern about a handwritten message on the resident's whiteboard stating, 'Stop abusing the call light, last warning.' The resident, who was deaf and used the whiteboard for communication, had no recollection of the message. Despite the initial report, the facility could not provide a final report or any documentation of interviews, observations, or interactions related to the investigation. The Director of Nursing and Assistant Director of Nursing at the time of the survey were unaware of the investigation details, and the family member of the resident expressed concerns about the lack of resolution and transparency regarding the incident. The facility's abuse policy mandates thorough investigation and documentation of abuse allegations, including identifying responsible staff members and reporting results to proper authorities. However, in this case, the facility did not follow through with these procedures. The family member of the resident, who had passed away, reported feeling unsettled by the lack of information and resolution regarding the threatening message. The facility's failure to complete and document the investigation represents a significant deficiency in ensuring resident safety and compliance with abuse prevention policies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 33 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sparta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coulterville Rehab & Hcc | 6.6 mi | — | 4 | 1 |
| Three Springs Sr Living & Rhab | 14.4 mi | — | 8 | 0 |
| Pinckneyville Nursing & Rehab | 17.4 mi | — | 0 | 0 |
| St Genevieve Nursing | 21.1 mi | — | 0 | 0 |
| La Bella Of Freeburg | 22.5 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Randolph County Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.