Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Radford Health And Rehab Center during CMS and state inspections, most recent first.
The facility staff failed to maintain accurate clinical records for several residents, leading to multiple deficiencies. A resident's medication administration was inaccurately recorded, another's meal and fluid intake documentation was incomplete, and a third resident's insulin administration was inconsistently documented. Additionally, a resident's use of a TLSO brace was inaccurately recorded. These issues highlight a systemic problem with maintaining accurate medical records.
A resident with chronic kidney disease and other conditions was not provided a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) as required for their October discharge. The Regional Director of Social Work confirmed the oversight, attributing it to the social worker's responsibility at the time. Despite the lapse, the resident reported no concerns.
The facility failed to implement its abuse prevention policy by not conducting reference checks for two new hires, an LPN and an SLP. Despite policies requiring reference checks, the facility could not provide documentation for these checks, leading to a deficiency.
A facility failed to notify the State Long-Term Care Ombudsman of an emergency transfer of a resident to the hospital. The resident, who was cognitively intact and had multiple medical conditions, was transferred for evaluation by a nurse practitioner. Despite facility policy requiring notification, the staff did not send a copy of the transfer notice to the ombudsman, as confirmed by the facility administration.
The facility staff failed to ensure accurate MDS assessments for three residents, leading to deficiencies in care documentation. A resident was incorrectly documented as experiencing dehydration, another was inaccurately indicated to have a stage 3 pressure ulcer, and a third resident's significant weight loss was not reflected in their MDS. These errors were acknowledged by the MDS Coordinator and discussed with facility leadership.
A facility failed to develop a baseline care plan for a hospice patient admitted for respite care. Despite the resident being oriented and having specific needs, the clinical documentation lacked a care plan addressing their hospice status. The deficiency was confirmed in a meeting with facility leadership.
A resident with acute cystitis and dementia was observed with a foley catheter, but it was not included in their care plan. The DON acknowledged the oversight, stating the catheter was discontinued and later reinstated, but the care plan was not updated accordingly. Facility policy requires care plans to be fluid and updated as needed, which was not followed.
A resident with severe cognitive impairment and multiple diagnoses did not receive hypertension medications as ordered because they were often asleep during administration times. Despite this recurring issue, the facility staff failed to notify or consult the medical provider to adjust the medication schedule, leading to a deficiency identified by surveyors.
A resident with bilateral cataracts did not receive assistance from facility staff to schedule a cataract surgery consultation, despite medical orders from an optometrist. The resident, who was cognitively intact, had worsening vision and expressed concerns during a survey. The facility's administration was unaware of the need for an appointment until the resident directly requested it, leading to a delay in scheduling the necessary consultation.
A resident with severe cognitive impairment and multiple medical conditions was not provided the correct tube feeding formula as ordered by their medical provider. The resident was observed receiving Osmolite 1.5 instead of the prescribed Isosource 1.5, which contains fiber. The facility's policy to administer tube feeding per physician orders was not followed.
A resident with a history of stroke and significant weight loss was receiving tube feeding, but the facility staff failed to label the enteral feeding formula and water with the necessary information, such as the name of the formula, date, and time initiated. This oversight was observed during a survey, despite the facility's policy requiring proper labeling of feeding equipment.
A resident with multiple health conditions was observed receiving oxygen at a rate higher than ordered by the medical provider. Despite the facility's policy requiring specific orders for oxygen adjustments, the resident's oxygen was set at 2.5 l/m instead of the ordered 2 l/m, without documented justification.
The facility failed to administer intravenous antibiotics to a resident as ordered and did not ensure the availability of Humira for another resident. The first resident's medication was delayed due to unavailability, while the second resident's medication was not administered due to issues with obtaining it from the family. These deficiencies were discussed with the facility's administration, but no further information was provided before the exit conference.
A resident with severe cognitive impairment and multiple health conditions was administered Loratadine without a current medical order. The medication had been discontinued weeks prior, yet it was still prepackaged for administration. The facility's policy requiring verification of medication against the MAR was not followed, leading to the deficiency.
The facility staff failed to ensure medications were consumed under direct observation for two residents. One resident, who was cognitively intact, was left with a pill unconsumed, while another severely cognitively impaired resident was left with Nystatin Oral Suspension unsupervised. The LPNs involved did not adhere to proper medication administration protocols, as confirmed by the DON.
Facility staff failed to obtain ordered lab tests for a resident with multiple health conditions, including MS and chronic kidney disease. Despite being cognitively intact, the resident's records lacked results for a UA and BMP, as ordered by the provider. The issue was reviewed with facility leadership, but no additional information was provided to the survey team.
The facility failed to maintain proper infection control practices, as observed in the treatment of a resident with severe cognitive impairment and a Stage 4 Sacral Pressure Ulcer. Staff did not perform hand hygiene between treatment stages, and soiled items were placed on the floor. Additionally, an LPN touched an oral medication tablet with bare hands before administration, violating facility policy.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility staff failed to maintain accurate clinical records for several residents, leading to multiple deficiencies. For Resident #13, the clinical documentation inaccurately recorded the administration of Ozempic injections, which were never sent to the facility. The resident's medication administration records (MARs) incorrectly indicated that both Ozempic and Trulicity were administered, despite the pharmacy confirming only Trulicity was sent. This discrepancy was confirmed by the Director of Nursing and highlighted a failure to adhere to the facility's policy on accurate medical record documentation. Resident #79's records showed a lack of documentation for meal and fluid intake on several occasions. The resident, diagnosed with multiple sclerosis, chronic kidney disease, and diabetes, required supervision with meals. However, documentation was missing for specific dates, and fluid intake was not consistently recorded for each shift. This omission was acknowledged by a Certified Nursing Assistant, who confirmed that fluid intake should be documented for every shift, as per facility policy. For Resident #81, the facility staff failed to document fluid intake, meal intake, bladder continence, and bowel movements consistently. The resident's clinical record for August 2023 revealed multiple documentation omissions, which were discussed with the Clinical Service Specialist and the Director of Nursing. Additionally, Resident #46's insulin administration was inaccurately documented, with discrepancies between the MAR and the resident's statements about insulin refusal. Lastly, Resident #67's records inaccurately documented the use of a TLSO brace, which was never provided to the resident. These deficiencies indicate a systemic issue with maintaining accurate and complete medical records in the facility.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility staff failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident, identified as R49, who was sampled for ABN review. R49 had diagnoses including chronic kidney disease stage IV, vascular dementia, iron deficiency anemia, peripheral vascular disease, and unsteadiness on feet. The resident's Minimum Data Set (MDS) assessment indicated intact cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. During the SNF Beneficiary Protection Notification Review, it was found that a SNF ABN should have been issued for R49's October 2024 discharge from SNF services, but it was not provided. The Regional Director of Social Work confirmed that the SNF ABN was not issued as required, stating that it was the responsibility of the social worker at the time. The facility's policy, which aligns with Medicare requirements, mandates that SNFs issue the SNF ABN to Original Medicare beneficiaries before providing care that Medicare may not cover. Despite the oversight, R49 expressed no concerns during an interview. The issue was discussed with the facility's administration and social work team, but no further information was provided to the survey team before the exit conference.
Failure to Implement Abuse Prevention Policy for New Hires
Penalty
Summary
The facility staff failed to implement their abuse prevention policy regarding the screening of new hires, specifically for two out of 25 new hires. New hire #3, an LPN, was initially hired on 9/1/20, terminated on 1/23/23, and rehired on 2/13/23. The facility did not provide evidence of reference checks for either hire date in the employee file. New hire #13, an SLP, was hired on 1/23/25, and similarly, no evidence of reference checks was provided. The administrator acknowledged that reference checks for new hire #3 could not be located, as they were done on paper in 2020. Additionally, the therapy contract company, Quality Care Rehab, did not require sharing reference checks with the facility, which contributed to the lack of documentation for new hire #13. The surveyor discussed these concerns with the facility's administration and staff during meetings on 2/5/25 and 2/6/25. The facility's policies, including the Abuse Prevention policy and the Hiring Process Policy, were reviewed. These policies required at least one reference check for potential employees and specified that rehired employees within one month did not need to complete new hire requirements. Despite these policies, the facility failed to provide the necessary documentation for the reference checks, leading to the identified deficiency.
Failure to Notify Ombudsman of Emergency Transfer
Penalty
Summary
The facility staff failed to provide a copy of the notification of reasons for transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for one of the sampled residents. This deficiency was identified for a resident who was transferred to the hospital for an emergency evaluation. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had multiple diagnoses including a non-displaced fracture of the right tibial tuberosity, pneumonia, chronic obstructive pulmonary disease, chronic kidney disease-stage 3, repeated falls, insomnia, and atrial fibrillation. The incident occurred when the resident was seen by a nurse practitioner and subsequently sent to the emergency department for evaluation. Despite the facility's policy requiring that copies of notices for emergency transfers be sent to the ombudsman, the facility staff did not provide such notification. This oversight was confirmed during a surveyor's review of the clinical record and discussions with the facility's administration, who acknowledged the absence of evidence that the ombudsman had been notified of the transfer.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility staff failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in their care documentation. Resident #52 was incorrectly documented as experiencing dehydration in their MDS assessment, despite clinical records lacking evidence to support this condition. The MDS Coordinator later acknowledged the error and modified the assessment to remove dehydration as a problem. Resident #61's MDS inaccurately indicated the presence of a stage 3 pressure ulcer upon admission, although the resident had no pressure ulcers. The clinical record only referenced a surgical wound, and the MDS Coordinator admitted the error, stating the MDS would be corrected. The incorrect coding was discussed with facility leadership, who were aware of the inaccuracy. For Resident #67, the facility staff failed to accurately complete Section K of the MDS to reflect an 8.37% weight loss. Despite documentation indicating significant weight loss and a diagnosis of protein-calorie malnutrition, the MDS was coded as if no weight loss had occurred. The error was identified during a review with a registered nurse, who confirmed the MDS should have included the weight loss. This concern was discussed with facility leadership during meetings with the survey team.
Failure to Implement Baseline Care Plan for Hospice Respite Resident
Penalty
Summary
The facility staff failed to develop and implement a baseline care plan for a resident admitted as a hospice patient for respite care. The resident, who was oriented to self, time, and place, and had adequate hearing but impaired vision, did not have a care plan addressing their specific needs as a hospice respite patient. The facility's policy requires the interdisciplinary team to identify immediate needs through assessments, interviews, and observations starting at admission. However, the clinical documentation lacked evidence of such a care plan. The deficiency was confirmed during a meeting with the facility's administration and nursing leadership, where the absence of a hospice care plan for the resident was acknowledged.
Failure to Include Foley Catheter in Resident's Care Plan
Penalty
Summary
The facility staff failed to ensure that a foley catheter was included in the care plan for a resident with multiple diagnoses, including acute cystitis without hematuria, obstructive and reflux uropathy, and unspecified dementia. The resident was observed on two separate occasions with a foley catheter bag hanging on the bed frame, yet the comprehensive care plan did not mention the foley catheter. The resident's minimum data set (MDS) assessment indicated the presence of a foley catheter, but this was not reflected in the care plan. Upon review, the Director of Nursing (DON) acknowledged that the foley catheter should have been included in the care plan. The DON initially stated that the catheter had been discontinued in January and the care plan was resolved, but later confirmed that the catheter was reinstated and updated in the care plan on the day of the surveyor's inquiry. The facility's policy on comprehensive care planning emphasizes the need for the care plan to be a fluid document, reviewed and updated as necessary, which was not adhered to in this case.
Failure to Administer Medications as Ordered Due to Resident's Sleep Pattern
Penalty
Summary
The facility staff failed to administer medications as ordered for a resident diagnosed with multiple conditions, including Hemiplegia, Atrial Fibrillation, and Vascular Dementia. The resident, who was severely cognitively impaired, had a care plan that required medications to be given as ordered by the physician. However, the resident's Medication Administration Records revealed that medications for hypertension were not administered on multiple occasions because the resident was asleep. Despite this recurring issue, there was no evidence that the medical provider was notified or consulted to adjust the medication administration times to accommodate the resident's sleep cycle. A nursing progress note indicated that the resident was often stuporous in the morning and would not wake up, even to painful stimulation, making it difficult to administer medications. The Director of Nursing acknowledged that the provider had not been notified about the missed medications due to the resident's sleeping pattern. This lack of communication and failure to adjust the medication schedule according to the resident's needs led to the deficiency identified by the surveyors.
Failure to Schedule Cataract Surgery Consultation
Penalty
Summary
The facility staff failed to assist a resident in scheduling an appointment for cataract surgery, as ordered by the medical provider. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had been diagnosed with bilateral cataracts, among other medical conditions such as Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. Despite the optometrist's orders on two separate occasions, in April and October of the previous year, to schedule a cataract surgery evaluation, the facility did not arrange the necessary consultation. The deficiency was identified during a survey when the resident expressed concerns about worsening vision due to cataracts. The survey team discussed the issue with the facility's administration, who were unaware of the need for an appointment until the resident directly requested it from the Unit Coordinator. The resident's clinical record later showed an appointment was finally scheduled for April of the following year, but this was after the survey team had already noted the deficiency.
Failure to Administer Correct Tube Feeding Formula
Penalty
Summary
The facility staff failed to ensure that a resident, who is fed by enteral means, received the appropriate tube feeding formula as ordered by the medical provider. The resident, identified as Resident #35, had a medical history that included hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, and a stage 4 sacral pressure ulcer. The resident was coded as severely impaired in cognitive skills and was receiving more than 51% of total calories through tube feeding. The medical provider's order specified Isosource 1.5 at 20 ml/hr, but the resident was observed receiving Osmolite 1.5, which does not contain fiber, unlike the ordered formula. During the survey, it was noted that the tube feeding formula bag was not labeled with the name of the formula or the date and time it was started. The surveyor observed two unopened containers of Osmolite 1.5 in the resident's room and confirmed with staff that the resident was receiving Osmolite 1.5. The facility's enteral feeding nutrition formulary indicated that the temporary replacement for Isosource 1.5 was Jevity 1.5, not Osmolite 1.5. The facility's policy required that tube feeding formulas be maintained according to the manufacturer's recommendations and administered per physician orders, which was not adhered to in this case.
Failure to Properly Label Enteral Feeding Equipment
Penalty
Summary
The facility staff failed to ensure proper labeling of enteral feeding equipment for a resident, leading to a deficiency in care. Specifically, the staff did not label the enteral feeding formula and water with the name of the formula, the date, and the time it was initiated. This oversight was observed during a survey when the resident was receiving tube feeding via a pump. The facility's policy requires that feeding equipment be properly labeled with the patient's name, date, type of feeding, rate, and start time, but this was not adhered to in the case of the resident. The resident involved had a history of stroke, dysphagia, and significant weight loss, and was at risk for nutritional decline. The resident was receiving more than 51% of their total calories through tube feeding and had a comprehensive care plan in place to address these needs. Despite this, the lack of proper labeling of the feeding equipment was noted on multiple occasions, indicating a failure to follow the facility's established procedures for the care of patients with feeding tubes.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and medical provider orders for a resident. The resident, who had a history of hemiplegia, hemiparesis, chronic obstructive pulmonary disease, and a stage 4 sacral pressure ulcer, was observed receiving supplemental oxygen at a rate of 2.5 liters per minute, contrary to the medical provider's order of 2 liters per minute. This discrepancy was noted on multiple occasions by the surveyor, who observed the resident in bed with the oxygen concentrator set at the incorrect rate. The facility's Director of Nursing confirmed that nurses are not permitted to adjust oxygen delivery rates without a specific order. Despite this, the resident's oxygen was set at 2.5 liters per minute without documented justification for the increase. The facility's policy on oxygen administration requires adherence to professional standards and the comprehensive person-centered care plan, which was not followed in this instance. The issue was discussed with the facility's administration, but no further information was provided to the survey team before the exit conference.
Medication Administration Failures
Penalty
Summary
The facility staff failed to ensure that Resident #33 received intravenous antibiotics as per the provider's order. The resident, who had diagnoses including acute osteomyelitis of the left ankle and foot, Type II diabetes with a skin ulcer, and chronic obstructive pulmonary disorder, was discharged from the hospital with an order to continue taking Zosyn intravenously every eight hours until the end of January 28, 2025. However, the Medication Administration Record (MAR) indicated that the medication was not administered as scheduled on January 22 and 23, 2025, due to the medication not being available. The Director of Nursing later confirmed that the medication was started two days later than ordered. For Resident #38, the facility staff failed to ensure the availability of the medication Humira, which is used to treat inflammatory conditions such as Crohn's disease. The resident's clinical record showed a physician's order for Humira to be administered weekly, but the medication was not available for administration on two occasions in January 2025. The nurse's progress notes indicated that the family was having problems obtaining the medication due to the original prescribing gastroenterologist no longer practicing in the area. The facility's policy required medications to be delivered directly to the facility by the pharmacy's agent, not by family members, but this was not adhered to. The surveyor discussed these concerns with the facility's administration and clinical staff, highlighting the failure to ensure medications were available for administration. The facility's policy on medication ordering and receipt was reviewed, which emphasized the need for medications to be delivered by the pharmacy's agent. Despite these discussions, no further information was provided to the survey team before the exit conference.
Unnecessary Drug Administration Without Order
Penalty
Summary
The facility staff failed to ensure that a resident's drug regimen was free from unnecessary drugs, as evidenced by the administration of Loratadine without a medical provider order. The resident, who was severely cognitively impaired with a BIMS score of 7 out of 15, had a history of Pneumonia, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Chronic Kidney Disease Stage 4. During a medication pass observation, a surveyor noted that an LPN administered a 10 mg tablet of Loratadine to the resident, despite the absence of a current order for the medication. The clinical record indicated that Loratadine had been ordered and discontinued on the same day, several weeks prior to the observation. Upon further investigation, it was discovered that Loratadine was prepackaged in the pharmacy's morning medications and was also included in the following day's package for administration. The facility's policy required verification of medication information against the MAR, which was not adhered to in this instance. The survey team discussed the issue with the facility's Administrator, Director of Nursing, and Clinical Service Specialist, but no additional information was provided before the exit conference.
Medication Administration Deficiency
Penalty
Summary
The facility staff failed to ensure that a physician-ordered medication was consumed under direct observation by the nursing staff for two residents. For one resident, who was cognitively intact, the medication nurse did not remain with the resident while he consumed all prescribed medications. The resident was observed attempting to pick up a pill left on the overbed table, and he reported that the nurse did not stay with him until he swallowed all his medications. The nurse explained that she sometimes left medications with alert and oriented residents who preferred to take their time swallowing their medications. However, the Director of Nursing confirmed that the nurse should have stayed with the resident until all medications were taken. In another instance, the facility staff left a medication, Nystatin Oral Suspension, with a resident who was severely cognitively impaired, to be taken unsupervised at a later time. During a medication pass observation, the LPN administered oral tablets and left the Nystatin on the resident's overbed table beside their breakfast tray. The resident's clinical record did not contain an order for self-administration of the medication. The Director of Nursing acknowledged the concern of leaving the medication unsupervised in the resident's room.
Failure to Obtain Ordered Lab Tests for a Resident
Penalty
Summary
The facility staff failed to obtain provider-ordered laboratory tests for a resident, leading to a deficiency. The resident, who had diagnoses including multiple sclerosis, chronic kidney disease stage 4, diabetes, and anorexia, was cognitively intact with a BIMS score of 14 out of 15. The clinical record showed orders for a urinalysis (UA) on two occasions and a basic metabolic panel (BMP) on another, but the surveyor could not find the results of these tests in the resident's records. The issue was discussed with the Director of Nursing, Administrator, and Clinical Service Specialist, but no further information was provided to the survey team before the exit conference.
Infection Control Deficiencies in Treatment and Medication Administration
Penalty
Summary
The facility staff failed to maintain an infection prevention and control program, as evidenced by the improper hand hygiene practices observed during treatment administrations for Resident #35. The resident, who was severely impaired in cognitive skills and had a diagnosis of Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease, and a Stage 4 Sacral Pressure Ulcer, was subjected to inadequate infection control measures. During a wound treatment, RN #2 did not change gloves or perform hand hygiene between different stages of the treatment, and soiled items were placed on the floor. Additionally, a community supply of Medi-Honey was used without proper hygiene, as the foil seal was removed with soiled gloves. On the Dogwood Unit, a nurse was observed touching an oral medication tablet with their bare hand before administering it to a resident, which is against the facility's policy. The LPN removed a Gabapentin tablet from a blister pack into their bare palm and then placed it into a medication cup for administration. This action was contrary to the facility's Paxit Med-Pass Procedure, which requires medication to be popped directly into a medication cup. These observations indicate a failure in adhering to established infection control protocols, compromising the safety and sanitary environment required to prevent the transmission of infections.
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Illustrative
What surveyors actually found near you
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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
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Illustrative
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Nursing homes near Radford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Ridge Rehab Center | 6.4 mi | ★★★★★ | 18 | 0 |
| The Wybe And Marietje Kroontje Health Care Center | 9.5 mi | ★★★★★ | 0 | 0 |
| Heritage Hall Blacksburg | 9.7 mi | ★★★★★ | 1 | 0 |
| Pulaski Hlth & Rehab Cntr | 11.3 mi | ★★★★★ | 2 | 0 |
| Skyline Nursing & Rehabilitation | 20.4 mi | ★★★★★ | 11 | 0 |
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