Shady Acres Health And Rehabilitation Center

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

head with her fist. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. No indication that the physical and verbal altercation was reported to the abuse coordinator. Record review of Resident #3's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #3 threw coffee on Resident #7, called her names and threatened to kill her. Resident #7 struck Resident #3 on the side of her head with her fist. The witnesses to the situation said Resident #3 was not provoked. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. No indication that the physical and verbal altercation was reported to the abuse coordinator. 5. Record review of Resident #7's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 stating she would beat her ass, LVN K was able to intervene and separate the residents. No indication that the verbal altercation was reported to the abuse coordinator. Record review of Resident #3's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 calling her an evil bitch LVN K was able to intervene and separate the residents. No indication that the verbal altercation was reported to the abuse coordinator.

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 #5Record 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 REDACTED] and readmitted on [DATE REDACTED]. 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

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Shady Acres Health and Rehabilitation Center

405 Shady Acres Lane Newton, TX 75966

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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

admitting to the situation, the allegation was confirmed. Resident #1 was immediately placed on 1:1 supervision with a new medication prescribed for Depo-Provera and referred to a behavioral hospital.

Resident #1 remained on 1:1 monitoring until transferred to behavioral hospital on [DATE REDACTED]. The sexual abuse allegation was not reported to the State Agency until 8/21/2025 at 11:32 a.m. greater than 2 hours

after the incident occurred. 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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Shady Acres Health and Rehabilitation Center

405 Shady Acres Lane Newton, TX 75966

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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

care plan revision or updates and that the MDS Coordinator or DON would be emailing/notifying the nursing staff of any changes in resident care plans and that CN should be contacting them for any care plans that need to be updated with changes in the resident's condition and to personalize the care plans to meet the resident's needs. LVN L said she was made aware verbally and electronically (email) of Resident #1 and Resident #3 had updates to their care plans which included the monitoring of Resident #1 and watching Resident #3 was agitated and to intervene before agitation escalates. 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

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