Inspection·December 2, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because they only had 1 CNA working so they were too short-staffed to do it. He was supposed to get one last Saturday too, on 11/1 but did not get it that day either because they also only had 1 CNA working. During an observation and interview on 12/01/2025 at 4:45 p.m., Resident #1 had on a dirty brief. Resident #1 stated that he always had on dirty briefs because everyone refused to change him. He stated that his call light was never answered and that he had to go to the nurses' station and beg for help. He stated that him and his family member had reported their concerns to the DON and Administrator and that nothing had been done about it. He stated that he felt ignored, and embarrassed. He stated that he had never refused a shower. Resident #2 Record review of Resident #2's electronic face sheet dated 12/02/2025 revealed a [AGE] year-old male admitted into facility on 06/16/2023 with diagnoses to include: diabetes, chronic kidney disease, and anxiety. Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 11 which indicated moderate cognitive impairment. Further review of the MDS indicated Resident #2 used a wheelchair and required partial/moderate assist with hygiene. Resident was occasionally incontinent of bowel and urine. Record review of Resident #2's care plan last revised on 10/11/2025 revealed residents preferred bath/shower on Tuesday, Thursday, and Saturday. Record review of Resident #2's POC documentation for the month of November 2025 revealed no evidence that Resident #2 had a bath/shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an observation and interview on 12/02/2025 at 11:00 a.m., Resident #2 was up in his wheelchair in his room. A foul smell was noted coming from the resident and his room. Resident #2 stated that he only received a shower once every 2 weeks. He stated that he was supposed to receive showers on Tuesday, Thursday, and Saturday. He stated that the staff always said that they were short-staffed and could not give him a shower. He stated that call-lights were never answered. He stated that he had reported his concerns to the DON, but there was always a new DON, and nothing was ever done. He stated that he had not ever refused a shower and that he was tired and stinking all of the time. Resident #3 Record review of Resident #3's electronic face sheet dated 12/02/2025, revealed a [AGE] year-old male admitted into the facility on [DATE] with diagnoses to include: alcohol abuse, muscle weakness, and malnutrition. Record review of Resident #3's quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS indicated Resident #3 used a wheelchair and required partial/moderate assist with hygiene. Resident was frequently incontinent of bowel and occasionally incontinent urine. Record review of Resident #3's care plan last revised on 10/11/2025 revealed residents preferred bath/shower on Tuesday, Thursday, and Saturday. Record review of Resident #3's POC documentation for the month of November 2025 revealed no evidence that Resident #1 had bath / shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an observation and interview on 12/02/2025 at 12:00 p.m., Resident #3 was lying in bed in his room. A foul smell was noted coming from the resident and his room. Resident #3 stated that he only received a shower once a week if he was lucky. He stated that the staff always said that there were short-staffed and could not give him a shower. He stated that call-lights were never answered. He stated that he was supposed to receive showers on Tuesday, Thursday, and Saturday. He stated that he was always embarrassed when he had visitors because he smelled bad. He stated that he had reported this to management multiple times and that nothing had changed. Record review of Resident Council meeting minutes dated 10/08/2025 revealed Nursing.2. We need a shower aide. They are not getting showers like they need to. 7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675330 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Oaks at Radford Hills Healthcare Center 725 Medical Dr Abilene, TX 79601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some or 8 days without one is not ok.4. A resident stated he asked the aide to give him a shower and did not get it.5. A resident pulled his light for 1 1/1 and no one came he saw an aide and asked her to change him and walked off. But a few minutes later he asked another member of staff who helped him an aide assist him, and it was aide he asked but she did not change him at that time. Record review of Resident Council meeting minutes dated 11/05/2025 revealed Nursing.1. We cannot function with 2 aides in the building.5. Call lights are not being answered in a timely manner.Nurses don't like to help at night. During an observation on 12/01/25 at 12:30 p.m., multiple call lights were lit up and ringing. Observed LVN-A and another nurse sitting at the nurses' station. During an interview on 12/01/2025 at 5:00 p.m., CNA-B stated that she was working on 11/22/25 when Resident #1's family member came to the facility very upset that he had been asking to be changed for over 45 minutes. She stated that it was mealtime and there were only 3 CNAs on shift at that time. She stated that her and CNA-C where in the dining room and the other CNA was passing hall trays and assisting residents with meals. She stated that she was feeding a resident when LVN-D came to her and asked her to go assist Resident #1 with a brief change. She stated that she left the dining room and noticed LVN-A and LVN-D where at the nurse's station along with Resident #1 and his family member. CNA-B stated that the facility was always short staffed and there was hardly ever more than 3 CNAs on duty. She stated that there was an ongoing issue with the nurses not helping the CNAs with any direct resident care and that she had reported this to the DON and ADON several times but that there was a new DON so often that it never got addressed. CNA-B stated that it was possible and most likely that the call light was going off for at least 45 minutes and that this was a normal occurrence because the nurses did not answer the call lights. She stated that she tried to complete all of the residents' showers and answer call-lights in a timely manner, but it was almost impossible. During an observation on 12/02/2025 at 11:00 a.m., multiple call lights were lit up and ringing. Observed LVN-A sitting at the nurses' station. Attempted interview on 12/02/2025 at 11:15 a.m. with LVN-D but unable to be contacted. During an interview on 12/02/2025 at 12:15 p.m., LVN-A stated that all staff members were required to answer call lights and that nurses should have assisted residents with all their care needs. She stated she worked on 11/22/2025 and that she had just walked up to the nurses' station when Resident #1's family member arrived and was upset. She stated that she was not aware of any residents not receiving their showers. During an interview on 12/02/2025 at 2:30 p.m., the ADON stated that the facility did not have a way of documenting and tracking showers. She stated that the aides completed a shower sheet daily and document who received and who refused showers. She stated that the shower sheet was turned in to the nurses and the nurses were responsible for documenting in the progress notes if a resident refused. She stated that the nurses were not very thorough and did not always document the refusals. She stated that the showers sheets were not kept and that there is no way to track when residents did or did not receive their showers. She stated that her expectation was for call lights to be answered immediate by all staff. She stated that she expected all showers to be completed unless refused by the resident. ADON stated that she had not been made aware that residents were not receiving showers or that nurses were not answering call lights. During an interview on 12/02/2025 at 2:45 p.m., the Administrator stated that her expectation was that call lights should have been answered as soon as possible and by all staff. Administrator stated that her expectation was that all residents received their showers every day that they are scheduled. She stated that she did not feel that the facility was short staffed and was not aware showers were not being given. Record review of facility policy titled Resident Rights dated February 2021 revealed: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675330 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Oaks at Radford Hills Healthcare Center 725 Medical Dr Abilene, TX 79601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 right to: a. a dignified existence; b. be treated with respect, kindness, and dignity. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675330 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Oaks at Radford Hills Healthcare Center 725 Medical Dr Abilene, TX 79601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings included: Record review of timesheets dated 11/01/2025 revealed 63.55 hours worked by direct care staff. Per facility PPD and census of 48 residents, 80.64 direct care staff hours were needed for 24-hour period. Record review of timesheets dated 11/06/2025 revealed 62.86 hours worked by direct care staff. Per facility PPD and census of 47 residents, 78.96 direct care staff hours were needed for 24-hour period. Record review of Resident #1's electronic face sheet dated 12/02/2025 revealed a [AGE] year-old male admitted into facility on 08/16/2025 with diagnoses to include: heart failure, urinary tract infection, diabetes, and diarrhea. Record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had a BIMS score of 06 which indicated severe cognitive impairment. Further review of the MDS indicated Resident #1 used a wheelchair and required partial/moderate assist with hygiene. Resident #1 was frequently incontinent of bowel and always incontinent of urine. Record review of Resident #1's care plan last revised on 12/02/2025 revealed: Problem: resident was at risk for pressure ulcers related to incontinence. Interventions: keep clean and dry as possible, minimize skin exposure to moisture. Record review of Resident #1's POC documentation for the month of November 2025 revealed no evidence that Resident #1 had bath / shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an interview on 11/30/2025 at 12:00 p.m., Resident #1's family member stated that on 11/06/2025, Resident #1 had soiled his brief (several times) and wheeled himself up to the nurses' station to ask them for help changing him. They gave the same response they always gave which is that they said a CNA would come help him as soon as all the breakfast trays had been picked up. No one came for 2 hours and in that period, he went several more times (in the toilet this time) but he had to put on the same dirty diaper that he had already soiled because no one had come to change him yet. She stated that he had to wheel himself back up there to the nurses' station to ask again. Family member stated that the resident was supposed to get a shower 3 times per week, but he did not get one yesterday 11/06/2025, because they only had 1 CNA working so they were too short-staffed to do it. He was supposed to get one last Saturday too, on 11/1 but did not get it that day either because they also only had 1 CNA working. During an observation and interview on 12/01/2025 at 4:45 p.m., Resident #1 had on a dirty brief. Resident stated that he always had on dirty briefs because everyone refused to change him. He stated that his call light was never answered and that he had to go to the nurses' station and beg for help. Record review of Resident #2's electronic face sheet dated 12/02/2025 revealed a [AGE] year-old male admitted into facility on 06/16/2023 with diagnoses to include: diabetes, chronic kidney disease, and anxiety. Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 11 which indicated moderate cognitive impairment. Further review of the MDS indicated Resident #2 used a wheelchair and required partial/moderate assist with hygiene. Resident was occasionally incontinent of bowel and urine. Record review of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675330 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Oaks at Radford Hills Healthcare Center 725 Medical Dr Abilene, TX 79601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #2's care plan last revised on 10/11/2025 revealed residents preferred bath/shower on Tuesday, Thursday, and Saturday. Record review of Resident #2's POC documentation for the month of November 2025 revealed no evidence that Resident #2 had a bath/shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an observation and interview on 12/02/2025 at 11:00 a.m., Resident #2 was up in his wheelchair in his room. A foul smell was noted coming from the resident and his room. Resident #2 stated he only received a shower once every 2 weeks. He stated he was supposed to receive showers on Tuesday, Thursday, and Saturday. He stated the staff always said that they were short-staffed and could not give him a shower. He stated the call-lights were never answered. Record review of Resident #3's electronic face sheet dated 12/02/2025, revealed a [AGE] year-old male admitted into the facility on [DATE] with diagnoses to include: alcohol abuse, muscle weakness, and malnutrition. Record review of Resident #3's quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS indicated Resident #3 used a wheelchair and required partial/moderate assist with hygiene. Resident was frequently incontinent of bowel and occasionally incontinent urine. Record review of Resident #3's care plan last revised on 10/11/2025 revealed residents preferred bath/shower on Tuesday, Thursday, and Saturday. Record review of Resident #3's POC documentation for the month of November 2025 revealed no evidence that Resident #1 had bath / shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an observation and interview on 12/02/2025 at 12:00 p.m., Resident #3 was lying in bed in his room. A foul smell was noted coming from the resident and his room. Resident #3 stated he only received a shower once a week if he was lucky. He stated the staff always said that there were short-staffed and could not give him a shower. He stated that call-lights were never answered. He stated he was supposed to receive showers on Tuesday, Thursday, and Saturday. During an interview on 12/01/2025 at 5:00 pm, CNA-B stated that the facility is always short staffed and there was hardly ever more than 3 CNAs on duty. She stated she tried to complete all of the residents' showers and answer call-lights in a timely manner, but it was almost impossible. During an interview on 12/02/2025 at 11:45 a.m., CNA-C stated when there was only 3 CNAs it was very difficult to answer call lights, especially during mealtimes. She stated 2 CNAs were in the dining room and there were 2 residents that required assist with feeding. She stated 1 CNA was supposed to monitor call-lights and hand out the hall trays. She stated that most days there were only 3 CNAs. During an interview on 12/02/2025 at 2:30 p.m., the ADON stated she staffed the facility based of resident needs. She stated the Administrator kept track of the PPD hours. She stated she always scheduled 4 to 5 CNAs for day shift and 3 CNAs for night shift. ADON stated that 3 CNAs was not enough direct care staff to meet the needs of the residents. She stated her expectation was for call lights to be answered immediate by all staff. She stated she expected all showers to be completed unless refused by the resident. ADON stated she had not been made aware that residents were not receiving showers or that nurses were not answering call lights. During an interview on 12/02/2025 at 2:45 p.m., the Administrator stated she did her staffing based on PPD. She was unable to recall the actual number of hours she staffed for. She stated she followed whatever was in the facility assessment. She stated direct care included all CNAs and CMAs. She stated that hospitality aides were not included in the numbers because they could not provide full resident care. The Administrator stated her expectation was that call lights be answered as soon as possible and by all staff. The Administrator stated her expectation was that all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675330 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Oaks at Radford Hills Healthcare Center 725 Medical Dr Abilene, TX 79601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete residents receive their showers every day when they were scheduled. She stated t she did not think the facility was short staffed and was not aware showers were not being given. Record review of Resident Council meeting minutes dated 10/08/2025 revealed Nursing.2. We need a shower aide. They are not getting showers like they need to. 7 or 8 days without one is not ok.4. A resident stated he asked the aide to give him a shower and did not get it.5. A resident pulled his light for 1 1/1 and no one came he saw an aide and asked her to change him and walked off. But a few minutes later he asked another member of staff who helped him an aide assist him, and it was aide he asked but she did not change him at that time. Record review of Resident Council meeting minutes dated 11/05/2025 revealed Nursing.1. We cannot function with 2 aides in the building.5. Call lights are not being answered in a timely manner.Nurses don't like to help at night. Record review of facility document titled Facility Assessment Tool last updated on 05/15/2025 revealed: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being.Direct Care Staff plan 24 hour nursing, to include licensed staff, med aides when available, CNA staffing based off of care needs with an Average HPPD 1.68 .Staffing assignments are based off of acuity and needs, resident physical and psychological needs which are part of the admission assessments. Assessments are not only completed on admission, quarterly and prn with sig changes and as requested. Event ID: Facility ID: 675330 If continuation sheet Page 7 of 7