The Oaks at Radford Hills Healthcare Center

In the surveyor’s words

From the most serious findings on record at The Oaks at Radford Hills Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 5, 2024

  Based 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]. […]

• Immediate jeopardy, isolatedF600Dec 9, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF607Dec 9, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Dec 9, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Jul 13, 2021

  Based on observation, interview and record review the facility failed to ensure 2 of 12 residents (Resident #20 and #62) reviewed were free from neglect. 1. The facility failed to ensure that Resident #20's Wanderguard and/or system was in working order, which led to resident eloping from the building and being missing for approximately 3 to 4 hours and resulted in abrasions to his left leg. 2. The facility failed to ensure that Resident #62's Wanderguard and/or alarm system was in working condition, which led to resident eloping from the building. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2021. […]