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Complaint Investigation

Shady Acres Health And Rehabilitation Center

October 23, 2025 · Newton, TX · 405 Shady Acres Lane
Citations 3
CMS Rating 1/5
Beds 84
Provider ID 676055
Healthcare Facility
Shady Acres Health And Rehabilitation Center
Newton, TX  ·  View full profile →
Inspection Summary

Shady Acres Health and Rehabilitation Center in Newton, TX — inspection on October 23, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Immediate Jeopardy

During an observation on 10/20/2025 at 11:00 a.m., Resident #7 was well groomed, and appropriately dressed. Resident #7 was lying in her bed resting.

She was easily aroused but did not respond appropriately to interview questions. Resident #7 with no signs of abuse or fear of staff identified. An attempted telephone interview on 10/20/2025 at 5:10 p.m. and 10/21/2025 at 12:27 p.m. with LVN K, was unsuccessful. 6.

Record review of Resident #3's progress note/behavior note dated 05/27/2025 authored by LVN H indicated Resident #3 punched an unidentified resident in her chest.

When asked why and what the other resident done to her, she stated, I don't remember, I just have so much anger inside.

Resident #5

Record review of Resident #5's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant i

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/23/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Shady Acres Health and Rehabilitation Center

405 Shady Acres Lane Newton, TX 75966

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 10/20/2025 at 3:00 p.m., LVN E interview said she did not routinely work in the secure unit, she was covering a shift, but she was familiar with the residents on the secure unit.

She said she is made aware during shift reports of any resident incidents, behaviors, monitoring required and task due.

She said she was not aware of any specific residents on the secure unit currently requiring 1:1 monitoring but due to the cognitive impairment of most of the secure unit residents they must be monitored closely.

She said the secure unit has a designated nurse, three CNAs and assistance from restorative aide and activity aide routinely during day shift, so plenty of staff for monitoring.

She said as a CN if an abuse allegation is reported to her, she responded immediately, separating involved individuals, and completed head to toe assessment, notified RP, MD, DON, Administrator/AC, hospice (if applicable) and followed orders as received. LVN E said she is aware of Resident #1's sexual behaviors but has not witnessed these behaviors during her assigned shifts.

She said Resident #3 did have a history of aggressive behaviors with Resident #4 & #5; Resident #4 has been moved off the secure unit so the two no longer have contact.

She said Resident #3 and #5 both still reside on the secure unit and staff attempt to prevent any altercations or interactions between the two.

She said they are both up in their wheelchairs in the hallways and that is when the incidents occur due to one b

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/23/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Shady Acres Health and Rehabilitation Center

405 Shady Acres Lane Newton, TX 75966

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 10/22/2025 at 2:30 p.m., LVN E said she was verbally and electronically notified of updated care plans on Resident #1, #3, #2, #4, #5, and #7.

She said Resident #1's care plan had changed, and he is being monitored q 15 minutes to identify any changes in his behaviors and Resident #3's care plan was updated to intervene immediately if agitation identified and the other care plan updates were to ensure residents safety.

During interviews conducted on 10/22/2025 at 9:10 a.m. through 10/23/2025 at 10:00 a.m. included LVN E, LVN H, LVN K, LVN L, LVN V, LVN BB, RN MM, and LVN NN.

All staff interviewed were able to identify care plans are person centered measures to maintain the resident's highest practicable physical well-being for skin integrity, meeting emotional, intellectual, physical, and social needs, ADL self-care, fall risk and diagnosis MDS.

All staff interviewed said resident's care plan should be reviewed and updated when residents have a change in condition, like falls with injuries, unmanaged or repetitive aggressive behaviors.

All staff interviewed said the MDS or DON would be notifying charge nurses via email or in person of any care plan updates and/or revision and if charge nurse identifies care plans that need to be revised or updated, they are to notify

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Newton, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Shady Acres Health and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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