The Oaks at Radford Hills Healthcare Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food was sealed and labeled properly in the kitchen freezer. The facility failed to ensure food was labeled in the kitchen refrigerator. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 medication carts (medication cart for Hall C) and 1 of 1 medication room reviewed for pharmacy services. The facility failed to ensure Resident #19's Nitroglycerin (medication used to treat chest pain) was not expired and was on the medication cart for Hall C. The facility failed to ensure that medications were labeled in Medication cart for C Hall on 03/17/2026. The facility failed to ensure 3 vials of Hepatitis B vaccine were not expired and were in the medication room refrigerator. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable and store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 3 medication carts (medication cart for Hall C) reviewed for pharmacy services. The facility failed to ensure medications were locked and labeled when unattended on Medication cart for C hall on 03/18/2026. This failure could place residents at risk of having access to unauthorized medications, leading to possible harm or drug diversions.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 8 of 13 (RN-A, CNA-D, CNA-E, CNA-F, HK-G, AD, Maint, and DOR) staff reviewed for training on dementia management, HIV, restraint reduction and prevention of falls. The facility failed to implement and maintain a training program that ensured RN-A, CNA-D, CNA-E, CNA-F received required dementia management training upon hire. The facility failed to implement and maintain a training program that ensured the DOR and HK-G received required dementia management training annually. The facility failed to implement and maintain a training program that ensured RN-A, CNA-D, CNA-E, CNA-F received required HIV training upon hire. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff on the elements and goals of the facility QAPI program for all new and existing staff for 4 of 13 (RN-A, CNA-D, CNA-F, and AD) staff reviewed for training on QAPI. The facility failed to ensure that RN-A, CNA-D, CNA-F, and AD were educated on the facility's QAPI program as part of their mandatory training requirements. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys during medication storage inspection for 3 (cart #1, cart #2, and cart #3) of 4 medication carts reviewed for storage. The facility failed to ensure medication carts #1, #2 and #3 were locked and secured while unattended. This failure could result in drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of (Resident #1, Resident #2, and Resident #3) 4 residents reviewed for dignity. The facility failed to ensure staff treated Resident #1 with dignity by not assisting resident with a brief change when asked on 11/22/2025. The facility failed to ensure staff treated Residents #1, #2, and #3 with dignity by not providing showers 3 times a week from 11/01/2025 until 11/30/2025. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.

Inspectors wroteBased on observation, interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance for 2 (11/01/2025 and 11/06/2025) of 4 days reviewed for sufficient staffing. The facility failed to maintain nurse staffing at the level indicated by the PPD budget on 11/01/2025 and 11/06/2025. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.

Inspectors wroteBased on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. for 2 of 4 residents (Resident #1 and Resident #2) reviewed for abuse and neglect. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to attain or maintain the resident's highest practicable mental and psychosocial well-being for 2 of 7 residents (Resident #1 and Resident #2) reviewed for Care Plans. The facility failed to ensure Resident #1's comprehensive care plan was revised following an incident where Resident #1 brought illegal drugs (meth) into the facility and attempted to smoke them. The facility failed to ensure Resident #2's comprehensive care plan was revised following an incident where Resident #2 attempted to smoke drugs (meth) with Resident #1. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #2) of 2 medication carts reviewed for storage. The facility failed to ensure medication cart #2 was locked and secured while unattended. This failure could result in a drug diversion.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure 1 of 6 residents (Resident #54) reviewed were free from neglect. 1. On 11/17/24 at 7:03:01 p.m. Resident #54 left the building unnoticed by staff, despite the wander guard alarm alarming at the exit door. Facility failed to implement immediate action to prevent neglect due to lack of supervision of 6 cognitively impaired individuals with known elopement risk which could result in falls, injuries, dehydration, and death. An Immediate Jeopardy (IJ) was identified on 12/6/24. The IJ template was provided to the facility on [DATE] at 2:45 pm. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure implementation of written policies and procedures that prohibit and prevent neglect for 1 of 6 residents (Resident #54) reviewed were free from neglect. 1. On 11/17/24 at 7:03:01 p.m. Resident #54 left the building unnoticed by staff, despite the wander guard alarm alarming at the exit door. 2. Facility failed to follow policy for emergency procedure-missing resident. 3. Facility failed to implement immediate action to prevent neglect due to lack of supervision of 6 cognitively impaired individuals with known elopement risk which could result in falls, injuries, dehydration, and death. An Immediate Jeopardy (IJ) was identified on 12/6/24. The IJ template was provided to the facility on [DATE] at 2:45 pm. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 (Resident #54, Resident #52) of 6 residents reviewed. 1. The facility failed to provide supervision for Resident # 54, who had a history of exit seeking behaviors, to prevent her from eloping from the facility on 11/17/24. 2. The facility failed to ensure that smoking materials (lighters, cigarettes) were not stored properly for 1 (Resident #52) of 17 residents listed as smokers. An Immediate Jeopardy (IJ) was identified on 12/6/24. The IJ template was provided to the facility on [DATE] at 2:45 pm. [...]

Inspectors wroteBased on interview the facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 6 (11/02/24, 11/03/24, 11/09/24, 11/15/24, 11/16/24, and 11/17/24) of 20 days reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 11/02/24, 11/03/24, 11/09/24, 11/15/24, 11/16/24, and 11/17/24. This failure left residents without the nursing administrative oversight that only the DON can provide.

Inspectors wroteBased on interviews and record review the facility failed to promptly resolve grievances for 12 of 12 confidential residents reviewed for grievances. The facility did not ensure grievance concerns voiced in a Resident Council meeting were addressed or that a resolution had been communicated back to 12 of 12 confidential residents. This deficient practice could place the residents at risk of unresolved grievances and a decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #6, Resident #30, Resident #68, and Resident #43) of 18 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of nebulized breathing treatments for Resident #6. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of oxygen therapy for Resident #30. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, and residents' choices during a confidential meeting for 12 of 12 residents reviewed for quality of care. The facility failed to ensure that licensed staff were not withheld resident wipes, which led to the staff having to use paper towels and toilet paper for resident care. This failure could put residents at risk of being unclean and skin sheer during direct resident care.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 3 of 18 residents (Resident #30, Resident #37, and Resident #54) reviewed for sufficient staffing The facility failed to ensure the facility had sufficient staffing based off facility assessment. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.

Inspectors wroteBased on interviews and record review, the facility failed to ensure drug regimen of each resident was reviewed at least once a month by a licensed pharmacist and failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #30) reviewed for (DRR) Drug Regimen Review. The facility failed to have record of Resident #30's medication regimen review for anti-psychotic medication since last survey on 10/19/2023. This failure could place resident as risk of not having their medications reviewed by pharmacy consultants for appropriate doses or pharmacy recommendations implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for the lunch meal on 11/18/24 and the supper menu on 11/19/24 for 2 of 2 meals (the lunch service on 11/18/24 and the supper service on 11/19/24) reviewed for nutritional adequacy. The facility did not serve the lunch menu posted for Monday 11/18/24, but instead served the lunch menu posted for Tuesday 11/19/24 and did not inform the residents that the menu would be switched. The facility did not follow the supper menu for Tuesday 11/19/24 and did not inform the residents that a substitute would be served. These failures could affect all residents who ate food from the kitchen by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standard or food service safety for 1 of 1 kitchen reviewed for food service safety in that: The facility failed to ensure all food items were labeled and dated. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. The failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 (CNA-B, CNA-C and CNA-D) staff observed during incontinent care. The facility failed to ensure CNA B, CNA C, and CNA D performed proper peri-care (incontinent care) and proper hand hygiene during peri-care for Resident #23 and Resident #12. These failures placed residents of the facility at risk of infections from improper incontinent care and hand hygiene while performing incontinent care.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training for 4 of 16 employees (DON, CNA B, LVN F, and RN I) reviewed for training. The facility did not ensure effective communication training was completed by the DON and CNA B during orientation. The facility did not ensure effective communication training was completed by RN I and LVN F annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training on resident rights mandatory training for 2 of 16 employees (RN I and LVN F) reviewed for training requirements in that: The facility did not ensure resident rights training was completed by RN I and LVN F annually. This failure could place residents at risk of receiving care from staff who were insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and dementia management for 2 (RN I and LVN F) of 19 employees reviewed for staff training. The facility did not ensure abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting training was completed by RN I and LVN F annually. These failure could place the residents at risk of abuse, neglect, exploitation, and misappropriation.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training an infection prevention and control program mandatory training for 4 of 16 employees (DON, CNA B, LVN F, and RN I) reviewed for training. The facility did not ensure an infection prevention and control program training was completed by the DON and CNA B during orientation. The facility did not ensure an infection prevention and control program training was completed by RN I and LVN F annually. These failure could affect residents and place them at risk of poor care or infections due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training on compliance and ethics mandatory training for 4 of 16 employees (DON, CNA B, LVN F, and RN I) reviewed for training. The facility did not ensure compliance and ethics training was completed by the DON and CNA B during orientation. The facility did not ensure compliance and ethics training was completed by RN I and LVN F annually. These failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interviews and record review, the facility failed to ensure before a resident was transferred or discharged that the facility notified the resident's guardian of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 residents (Resident #54) reviewed for transfer or discharge. The facility failed to provide Resident #54 ' s guardian written notice of the resident ' s transfer before Resident #54 was transferred to Facility B on 11/29/2024. The facility failure could affect residents who were discharged from the facility and could place them at risk of having their discharge rights violated.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 (Resident #36) of 1 resident records reviewed for closed records. include the discharge assessment was not transmitted to CMS within 14 days of completion. The facility did not ensure the discharge MDS assessment was completed and electronically transmitted as required for Resident #36. This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for resident records. The facility failed to ensure CNA B documented the accurate dinner meal intake for Resident #1. These failures could place residents at risk of weight loss and a decline in health status.

Inspectors wroteBased on interview, and record review the facility failed to inform the resident representative of a significant change in the residents' physical status and the need to significantly alter the resident's treatment for 1 of 3 residents (Resident #1) reviewed for notification. The facility failed to notify Resident #1's representative of hospital transfer on 09/16/2024 resulting in resident not having an advocate the make decisions at the hospital. This failure could affect residents by placing them at risk for not having an advocate, delay in medical treatment, or decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 4 residents' rooms reviewed for homelike environment, in that: 1. Resident #2's bathroom tile was discolored and covered in multiple dried, dark brown stains, toilet base caulking and tile grout lines were covered in a dark black substance, and the cove base around the wall and floor between the toilet and inside wall had an indention and had pulled away from the wall, which exposed the drywall. Resident #2's floor in his room was wet and stained with dark streaks; a piece of toilet paper was observed on the floor with a wet, brown substance, and Resident #2's oxygen machine had a dried liquid stain that ran down the front of the machine and several dried splatter spots. 2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on 7/14/23. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes.

Inspectors wroteBased on record review and interview the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 1 of 3 residents (Residents #1) reviewed for care plans as follows: Resident #1 did not have a care plan for going out on pass for personal needs. These failures could place residents at risk of not receiving the care required to meet their Individualized needs.

Inspectors wroteBased on interview and record review the facility failed to ensure orders were provided for the resident's immediate care and needs for 1 of 3 residents (Resident #1) reviewed. The facility failed to ensure a physician order was put in-place/received to allow Resident #1 to go out on pass daily. This failure had the potential to place residents at risk of not having their medical care supervised.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for multiple falls. The facility failed to implement appropriate interventions for Resident #1 to prevent 5 falls within 19 hours from [DATE] at 12:30pm to [DATE] at 7:30am, that lead Resident #1's Family Member B calling 911, which resulted in hospitalization with diagnoses of subarachnoid hemorrhage (brain bleed) and L3 fracture (lumbar spine fracture) which resulted in death on [DATE]. The facility failed to identify fall risk or implement any interventions in the Plan of Care for Resident #2 who was a known fall risk and had falls on [DATE] and [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 2 (Resident #2 and Resident #4) of 10 residents reviewed for baseline care plans. The facility failed to ensure that Resident #2 had baseline care plan developed within 48 hours after being admitted to the facility on [DATE]. The facility failed to ensure that Resident #4 had a baseline care plan developed within 48 hours after being admitted to the facility on [DATE]. These failures placed the residents at risk of not having continuity of care to safeguard against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #2 and Resident #3) of 10 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of risk for falls for Resident #2. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of risk for falls for Resident #3. This failure could place the residents at risk for decreased quality of life and not having their needs met.

Inspectors wroteBased on interview, and record review, the facility failed to ensure nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 2 (Resident #1 and Resident #2) out of 2 residents reviewed for administration of medications and maintaining a central line. The facility failed to ensure LVN A had the knowledge and skills to provide nursing services to 2 residents (Resident #1 and Resident #2) receiving intravenous medications. This failure could place residents at risk for worsening or spread of infection that could impact level function and/or physical health and well-being.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: The facility's kitchen staff failed to wear hair net during meal preparations. The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. These failures placed residents at risk for food borne illness and cross-contamination.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and maintain an effective training program for all new and existing staff for 9 of 15 (ADMIN, DON, SW E, DM, RN F, LVN G, LVN H, LVN J, HSK K) personnel files reviewed for training. 1. The facility failed to train for Communications for SW E, DM, RN-F, LVN-SM, LVN-HP, and HSK K. 2. The facility failed to train for Resident Rights for SW E, DM, RN F, LVN G, and HSK K. 3. The facility failed to train for Infection Control for SW E and DM. 4. The facility failed to train for Compliance and Ethics for SW E and DM. 5. The facility failed to train for HIV either during orientation or annually for DON, DM, RN F, LVN G, LVN J, and HSK K. 6. The facility failed to train for Restrain Reduction during orientation or annually for ADMIN, DON, DM, RN F, LVN G, LVN H, LVN J, and HSK K. 7. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and maintain an effective communications training program for all new and existing staff for 6 of 15 (SW E, DM, RN F, LVN G, LVN J, and HSK K) personnel files reviewed for training. The facility failed to train for Communications for SW E, DM, RN F, LVN-G, LVN J, and HSK K. These failures placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and maintain an effective Resident Rights and Facility Responsibilities training program for all new and existing staff for 5 of 15 (SW E, DM, RN F, LVN G, and HSK K) personnel files reviewed for training. The facility failed to train for Resident Rights for SW E, DM, RN F, LVN G, and HSK K. These failures placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to participate in the development and implementation of his person-centered plan of care for one (Resident #64) of one resident reviewed for person-centered plans of care. The facility failed to include Resident #64 in her Care Plan Conference. This failure could affect residents and place them at-risk by contributing to inadequate care.

Inspectors wroteBased on interview and record review the facility failed to transmit an MDS for 1 of 3 (Resident #13) residents reviewed for closed records. Facility failed to transmit a Discharge MDS for Resident #13 on 6/08/2023. This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and maintain an effective Infection Control training program for all new and existing staff for 2 of 15 (SW E and DM) personnel files reviewed for training. The facility failed to train for Infection Control for SW E and the DM. These failures placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and maintain an effective Compliance and Ethics training program for all new and existing staff for 9 of 15 (SW E, DM) personnel files reviewed for training. The facility failed to train for Compliance and Ethics for SW E and the DM. These failures placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 6 days out of 143 days reviewed for RN coverage. The facility failed to have an RN coverage for 8 consecutive hours 7 days a week on October 30, 2022, February 26, 2023, March 26, 2023, May 21, 2023, August 25, 2023, and October 1, 2023. These failures could place all residents at risk for their clinical needs not being met.