Randolph, NE

Colonial Manor of Randolph

1-star overall rating with 1-star inspections with 12 recent health deficiencies

811 South Main Street, Randolph, NE

(402) 337-0444

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

1996-04-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.73

Registered nurse staffing · state 0.71 · national 0.68

LPN hours / resident day

0.54

Licensed practical nurse staffing · state 0.71 · national 0.87

Aide hours / resident day

2.12

Nurse aide staffing · state 2.76 · national 2.35

Total nurse hours

3.39

All reported nurse hours · state 4.17 · national 3.89

Licensed hours

1.27

RN + LPN hours · state 1.41 · national 1.54

Weekend hours

2.91

Weekend nurse staffing · state 3.61 · national 3.43

Weekend RN hours

0.38

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.18

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.82

CMS adjusted RN staffing hours

Adjusted total hours

3.78

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

47%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,517

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

35.93

Composite VBP score used to determine payment impact.

Payment multiplier

0.9895

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

5.79

Baseline 35.90% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 0

Adjusted total nurse staffing

1.39

Baseline 3.52 hours · Performance 3.47 hours · Measure score 1.39 · Achievement 1.39 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.35%	10.72% 1.4 pts better	No Different than the National Rate · Eligible stays 42 · Observed rate 2.38% · Lower 95% interval 5.89%
Discharge to community	38.92%	50.57% 11.6 pts worse	No Different than the National Rate · Eligible stays 37 · Observed rate 29.73% · Lower 95% interval 26.25%
Medicare spending per beneficiary	1.31	1.02 0.3 pts worse
Drug regimen review with follow-up	97.14%	95.27% 1.9 pts better	Numerator 34 · Denominator 35
Falls with major injury	2.86%	0.77% 2.1 pts worse	Numerator 1 · Denominator 35
Discharge self-care score	25.93%	53.69% 27.8 pts worse	Numerator 7 · Denominator 27
Discharge mobility score	40.74%	50.94% 10.2 pts worse	Numerator 11 · Denominator 27
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 35 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	10.98%	8.2% 2.8 pts better	Numerator 9 · Denominator 82
Staff flu vaccination coverage	41.35%	42% 0.6 pts worse	Numerator 43 · Denominator 104
Discharge function score	55.56%	56.45% 0.9 pts worse	Numerator 15 · Denominator 27
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	1.8 0.6 pts better	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.7	2.0 1.3 pts better	1.8 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.3%	92.8% 2.5 pts better	93.4% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 90.9% · Q3 100.0% · Q4 97.6% · 4Q avg 95.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.6%	96.1% 1.5 pts better	95.5% 2.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6%
Percentage of long-stay residents experiencing one or more falls with major injury	3.3%	4.5% 1.2 pts better	3.3% About the same	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.0% · Q3 2.6% · Q4 4.9% · 4Q avg 3.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	8.0%	4.4% 3.6 pts worse	11.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 12.9% · Q3 7.9% · Q4 5.1% · 4Q avg 8.0%
Percentage of long-stay residents who lose too much weight	6.0%	5.3% 0.7 pts worse	5.4% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 0.0% · Q3 8.6% · Q4 2.8% · 4Q avg 6.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.4%	19.5% 8.1 pts better	19.6% 8.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 6.7% · Q3 11.1% · Q4 10.5% · 4Q avg 11.4%
Percentage of long-stay residents who received an antipsychotic medication	23.7%	21.6% 2.1 pts worse	16.7% 7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 20.8% · Q3 22.6% · Q4 22.6% · 4Q avg 23.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.3% 0.3 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	23.9%	20.4% 3.5 pts worse	16.3% 7.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q4 22.5% · 4Q avg 23.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	20.0%	19.9% 0.1 pts worse	14.9% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 25.0% · Q3 15.6% · Q4 16.2% · 4Q avg 20.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.2%	1.6% 0.4 pts better	1.0% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.8%	2.9% 0.1 pts better	1.7% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.7% · Q3 0.0% · Q4 2.6% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.1%	26.6% 1.5 pts worse	19.8% 8.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 26.8% · Q3 36.4% · Q4 23.3% · 4Q avg 28.1%
Percentage of long-stay residents with pressure ulcers	6.9%	4.3% 2.6 pts worse	5.1% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 2.9% · Q3 5.9% · Q4 8.7% · 4Q avg 6.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	82.1%	80.5% 1.6 pts better	81.7% 0.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 81.8% · 4Q avg 82.1%
Percentage of short-stay residents who had an outpatient emergency department visit	4.5%	11.6% 7.1 pts better	12.0% 7.5 pts better	Short Stay · 20240701-20250630 · Adjusted 4.5% · Observed 3.8% · Expected 9.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.8%	2.4% 0.4 pts worse	1.6% 1.2 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 2.8% · Used in QM five-star
Percentage of short-stay residents who were rehospitalized after a nursing home admission	18.9%	20.9% 2 pts better	23.9% 5 pts better	Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 15.4% · Expected 19.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-10 · Fire 2025-12-10

12 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-10-03 · Fire 2024-10-03

7 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

4 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2023-09-14 · Fire 2023-09-14

3 health deficiencies

Top issue: Infection Control (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-03

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-11-15

E · Potential for more than minimal harm 2024-10-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-02

E · Potential for more than minimal harm 2024-10-03

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2024-11-01

E · Potential for more than minimal harm 2024-10-03

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2024-10-02

E · Potential for more than minimal harm 2023-09-14

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2023-10-09

E · Potential for more than minimal harm 2023-09-14

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2023-10-09

E · Potential for more than minimal harm 2023-09-14

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-10-09

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-12-10

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2026-01-05

E · Potential for more than minimal harm 2025-12-10

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2026-01-05

D · Potential for more than minimal harm 2025-12-10

F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Corrected 2026-01-05

D · Potential for more than minimal harm 2025-12-10

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2026-01-05

D · Potential for more than minimal harm 2025-12-10

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2026-01-05

C · Minimal harm 2025-12-10

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2026-01-05

F · Potential for more than minimal harm 2025-11-24

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2025-12-22

F · Potential for more than minimal harm 2025-11-24

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2025-12-15

F · Potential for more than minimal harm 2025-11-24

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-12-22

E · Potential for more than minimal harm 2025-11-24

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-12-22

D · Potential for more than minimal harm 2025-11-24

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-12-22

D · Potential for more than minimal harm 2025-11-24

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-12-22

F · Potential for more than minimal harm 2024-10-03

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-11-15