The Oaks At Radford Hills Healthcare Center

Penalties

• Dec 9, 2024 — Payment Denial · payment denial 1 days
• Dec 9, 2024 — Fine ($15,099)
• Apr 5, 2024 — Fine ($148,552)
• Apr 5, 2024 — Payment Denial · payment denial 19 days

Inspection findings

1. Mar 19, 2026 Fire Safety · 9 findings
   • Not serious Scope/severity F

     E0020 Emergency Preparedness Deficiencies

     Establish policies and procedures including evacuation.

     Corrected Apr 27, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity C

     F0940 Administration Deficiencies

     Develop, implement, and/or maintain an effective training program for all new and existing staff members.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity C

     F0944 Administration Deficiencies

     Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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 Apr 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Apr 14, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 14, 2026 · CMS fire safety

2. Dec 9, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Dec 10, 2025 · CMS health inspection

3. Dec 2, 2025 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Dec 12, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0725 Nursing and Physician Services Deficiencies

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

     Corrected Dec 12, 2025 · CMS health inspection

4. Apr 16, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Apr 30, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Apr 30, 2025 · CMS health inspection

5. Dec 17, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Dec 19, 2024 · CMS health inspection

6. Dec 9, 2024 Health · 22 findings
   • Not serious Scope/severity E Complaint

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Jan 8, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jan 8, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity B Complaint

     F0640 Resident Assessment and Care Planning Deficiencies

     Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jan 8, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0725 Nursing and Physician Services Deficiencies

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

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0727 Nursing and Physician Services Deficiencies

     Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0803 Nutrition and Dietary Deficiencies

     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 Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0941 Administration Deficiencies

     Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0942 Resident Rights Deficiencies

     Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0943 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0945 Infection Control Deficiencies

     Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0946 Administration Deficiencies

     Provide training in compliance and ethics.

     Corrected Jan 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Jan 6, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jan 6, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 6, 2025 · CMS fire safety

7. Oct 24, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Nov 17, 2024 · CMS health inspection

8. Oct 3, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Oct 16, 2024 · CMS health inspection

9. Sep 11, 2024 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     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 Sep 30, 2024 · CMS health inspection

10. Jul 3, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0623 Resident Rights Deficiencies

      Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

      Corrected Jul 4, 2024 · CMS health inspection

11. May 2, 2024 Health · 2 findings
    • Not serious Scope/severity E Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected May 22, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0710 Nursing and Physician Services Deficiencies

      Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

      Corrected May 22, 2024 · CMS health inspection

12. Apr 5, 2024 Health · 3 findings
    • Not serious Scope/severity E Complaint

      F0655 Resident Assessment and Care Planning Deficiencies

      Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

      Corrected Apr 22, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Apr 22, 2024 · CMS health inspection

    • Serious Scope/severity K Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Apr 22, 2024 · CMS health inspection

13. Feb 16, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0726 Nursing and Physician Services Deficiencies

      Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

      Corrected Mar 15, 2024 · CMS health inspection

14. Oct 19, 2023 Fire Safety · 11 findings
    • Not serious Scope/severity F

      E0004 Emergency Preparedness Deficiencies

      Develop and maintain an Emergency Preparedness Program (EP).

      Corrected Nov 10, 2023 · CMS fire safety

    • Not serious Scope/severity D Complaint

      F0553 Resident Rights Deficiencies

      Allow resident to participate in the development and implementation of his or her person-centered plan of care.

      Corrected Nov 10, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0640 Resident Assessment and Care Planning Deficiencies

      Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

      Corrected Nov 10, 2023 · CMS health inspection

    • Not serious Scope/severity C Complaint

      F0727 Nursing and Physician Services Deficiencies

      Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

      Corrected Nov 10, 2023 · CMS health inspection

    • Not serious Scope/severity F Complaint

      F0812 Nutrition and Dietary Deficiencies

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

      Corrected Nov 10, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0940 Administration Deficiencies

      Develop, implement, and/or maintain an effective training program for all new and existing staff members.

      Corrected Nov 10, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0941 Administration Deficiencies

      Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

      Corrected Nov 10, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0942 Resident Rights Deficiencies

      Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

      Corrected Nov 10, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0945 Infection Control Deficiencies

      Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

      Corrected Nov 10, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0946 Administration Deficiencies

      Provide training in compliance and ethics.

      Corrected Nov 10, 2023 · CMS health inspection

    • Not serious Scope/severity D

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Oct 19, 2023 · CMS fire safety

15. Aug 31, 2023 Health · 1 finding
    • Not serious Scope/severity E Complaint

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Sep 20, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BOSWELL, DARREN — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/03/2025
• EDEN, JAMES — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/03/2025
• LEONARD, JOSHUA — operational/managerial control, NOT APPLICABLE, since 10/01/2024
• MARTINEZ IRIZARRY, AXEL — adp of the snf, NOT APPLICABLE, since 07/08/2023
• WHITWORTH, GARY — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/03/2025
• WRIGHT, LABAN — corporate officer, NOT APPLICABLE, since 11/10/2021
• ZAHODNIK, MATHEW — adp of the snf, NOT APPLICABLE, since 08/20/2024
• EASTLAND MEMORIAL HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 04/01/2021
• HART-LINE ASSOCIATES LP — adp of the snf, NOT APPLICABLE, since 08/01/2019
• HART-LINE ASSOCIATES LP — 5% or greater mortgage interest, NOT APPLICABLE, since 08/01/2019
• SLP ABILENE II LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2021