Inspection Reports for The Oaks at Radford Hills

The facility failed to ensure that medication carts #1, #2, and #3 were locked and secured while unattended, posing a risk of drug diversion. Observations and interviews revealed that these carts were found unlocked with medications accessible, and staff acknowledged lapses in following protocols for locking medication carts.

The complaint investigation found substantiated issues including residents not receiving showers as scheduled, call lights not being answered timely, staff shortages, and failure to assist residents with hygiene needs. Residents and family members reported repeated concerns to management without resolution.

The facility failed to ensure residents were treated with dignity and respect, including failure to assist with brief changes and provide showers as scheduled. Additionally, the facility did not maintain sufficient nursing staff hours to meet resident care needs, resulting in unmet hygiene needs and unanswered call lights.

The complaint investigation was substantiated as the facility failed to report the incident involving illegal drugs and attempted smoking by two residents to the state agency as required by policy and regulations.

The facility failed to report the incident involving illegal drugs and attempted smoking by two residents to the state agency within the required timeframe. Additionally, the facility failed to develop and implement comprehensive care plans for the involved residents reflecting the incident and their behavioral needs. The residents were caught with methamphetamine and drug paraphernalia, but no drugs were smoked or ingested. The facility staff and administration did not consider the incident reportable due to no actual ingestion or harm occurring.

The facility failed to ensure that medication cart #2 was locked and secured while unattended, posing a risk of drug diversion. Interviews with staff confirmed the cart was left unlocked, and facility policy requires medication carts to be locked at all times when not in use.

The complaint investigation focused on grievances not being resolved, resident neglect and elopement, inadequate staffing, failure to notify guardians of transfers, incomplete care plans, improper infection control, and lack of staff training. Immediate Jeopardy was identified related to resident elopement and lack of staff training on door alarms and elopement procedures.

The facility failed to promptly resolve grievances, ensure resident safety from neglect and elopement, maintain adequate staffing, provide proper care and training, follow menus, and maintain infection control and food safety standards. Immediate Jeopardy was identified related to resident elopement and lack of staff training on door alarms and elopement procedures. The facility implemented a Plan of Removal and provided staff education and monitoring.

The complaint investigation was substantiated with findings of unresolved grievances, neglect related to elopement, failure to notify guardian of transfer, inadequate staffing, incomplete care plans, infection control deficiencies, menu deviations, and lack of required staff training.

The facility failed to promptly resolve grievances for 12 residents, failed to prevent elopement of a cognitively impaired resident, failed to notify the guardian of a resident's transfer, failed to maintain adequate staffing, failed to ensure proper care plans, failed to provide adequate infection control and hand hygiene, failed to follow menus, and failed to provide required staff training.

The complaint investigation found that Resident #1's dinner meal intake was inaccurately documented by CNA B, who recorded that the resident ate 75-100% of her dinner when she only ate 1-2 bites and did not swallow the food. The ADON, DON, and Administrator all confirmed the documentation error and stressed the importance of accurate diet documentation to prevent weight loss and health decline.

The facility failed to ensure accurate documentation of Resident #1's dinner meal intake, with CNA B inaccurately recording that the resident ate 75-100% of her dinner when she only ate 1-2 bites and was unable to swallow the food. Interviews with staff confirmed the documentation error and emphasized the importance of accurate diet documentation to prevent health decline.

The complaint investigation found that the facility did not notify Resident #1's legal guardian of the hospital transfer on 09/16/2024. The resident representative confirmed not being notified and expressed concerns about decision-making for residents. The facility acknowledged communication failures, especially due to inconsistent nursing staff and agency personnel.

The facility failed to notify Resident #1's representative of the hospital transfer on 09/16/2024, resulting in the resident not having an advocate during hospital care. Interviews with staff confirmed that notification responsibilities were not met due to communication gaps, particularly involving agency staff.

The facility failed to maintain a safe, clean, and homelike environment for residents, specifically noting unsanitary conditions and physical disrepair in the bathrooms and rooms of two residents. Issues included stained and cracked tiles, exposed drywall, unclean medical equipment, and poor housekeeping practices, which could place residents at risk of psychosocial harm and unsanitary living conditions.

The complaint was substantiated based on interviews and record review showing the facility did not send required transfer/discharge notices to the Ombudsman since 3/29/24, including for Resident #1 discharged on 7/14/23.

The facility failed to send a transfer or discharge notice in writing to the Ombudsman as soon as practicable when Resident #1 was discharged home on 7/14/23, potentially affecting residents' access to advocacy services and appeal processes.

The facility failed to develop a comprehensive care plan for Resident #1 to address going out on pass for personal needs and failed to obtain a physician's order allowing Resident #1 to go out on pass daily. These deficiencies posed risks to residents' safety and medical supervision.

The complaint investigation revealed failures in baseline and comprehensive care planning and fall prevention measures. Resident #1 experienced 5 falls within 19 hours leading to hospitalization and death. The facility was not aware of the extent of falls and failed to notify family members timely. Interviews with staff revealed confusion about responsibilities for care plans and fall risk interventions. An Immediate Jeopardy was identified and a Plan of Removal was implemented.

The facility failed to develop baseline care plans within 48 hours for two residents, failed to develop comprehensive care plans addressing fall risks for two residents, and failed to provide adequate supervision and fall prevention interventions for three residents, resulting in multiple falls including one resident's death. The facility demonstrated confusion and miscommunication regarding staff responsibilities for care plans and fall risk management.

The complaint alleged missed doses of IV antibiotics for Resident #1 due to staffing with agency personnel and lack of nurse experience with PICC lines. The complainant stated Resident #1 was sent to the emergency room because the nurse reported a clogged PICC line, but the ER physician found no issue with the line.

The facility failed to ensure that nurses, specifically LVN A, had the appropriate competencies to provide nursing services related to intravenous medication administration and central line maintenance for two residents. Missed doses of IV antibiotics were documented, and the facility lacked a policy on nursing staff skills competency for IV therapy.

The facility was found deficient in multiple areas including failure to involve a resident in care plan meetings, failure to transmit a discharge MDS timely, inadequate RN coverage, food safety violations, and lack of required staff training in communications, resident rights, infection control, compliance and ethics, HIV, restraint reduction, fall prevention, and dementia care.

The facility failed to ensure resident participation in care planning, timely transmission of MDS assessments, consistent RN coverage, proper food safety practices, and comprehensive staff training in multiple required areas including communication, resident rights, infection control, compliance and ethics.

The facility failed to ensure staff treated residents with respect and dignity while removing personal care products from their rooms, affecting 2 of 6 residents reviewed. Staff removed residents' personal items without proper communication or respect, potentially diminishing residents' quality of life and self-esteem.

The investigation was complaint-driven, focusing on inadequate care plans for residents requiring assistance with transfers and multiple complaints about food quality, temperature, and kitchen sanitation issues. Substantiation status is not explicitly stated.

The facility failed to develop and implement comprehensive care plans addressing residents' transfer needs, specifically the use of Hoyer lifts and required staff assistance. Additionally, the kitchen failed to provide palatable, properly prepared food served at safe temperatures, and did not maintain proper food safety and sanitation standards, including pest control and employee hygiene.

The facility failed to maintain an effective infection prevention and control program, as evidenced by a CNA's failure to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1, potentially placing residents at risk for infection spread.

The facility was found deficient in multiple areas including failure to involve resident representatives in care planning, failure to assess and monitor self-administration of medications, failure to notify legal guardians of significant resident condition changes, failure to complete and provide baseline care plans within 48 hours of admission, improper medication storage and security, improper food storage and labeling, and inadequate infection prevention and control practices including poor wound and catheter care.