Shady Acres Health And Rehabilitation Center
Shady Acres Health and Rehabilitation Center in Newton, TX — inspection on April 29, 2026.
Found 5 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.
Inspection Findings
every day of the week. He said he expected there to be an acting DON or full-time DON in the facility.
hire and a DON, advertising the position on different platforms in the past, and just recently added
for DON next week. He said his desire to hire someone more experienced in management of resident care and staff, and the fact that the area is rural led to the failure of the DON position not to be filled.
He said he was the one who was responsible for making sure there was a DON and the facility had RN coverage.
The Administrator said he was not aware there was no RN coverage on those dates, but what could he do if there were no RNs available to work.
Administrator said there was no corporate RN or Regional RNs to assist in the DON roll until one is hired.
The Administrator said he was aware of the importance of having an RN at the facility for clinical management.
The Administrator said the Director of Nurses was responsible for ensuring RN coverage as required and notifying Administrator of non-coverage. He stated there was improvement to be made, and the management was aware of the issue prior to today.
The Administrator said that there were no reported quality concerns attributable to the lack of RNs or DONs coverage. He said no residents missed services or treatment because an RN was not onsite.
The Administrator said it was important to have RN coverage because they were more skilled than an LVN and were able to assess patients differently. He said he had some quality LVNs better than the last DONs hired.
The Administrator said they were interviewing one or two candidates for an RN DON at the end of the week.
Record review of the facility's policy titled Director of Nursing Services, dated August 2006, read in part: Policy Statement: The Nursing Services department is under the direct supervision of a Registered Nurse.1.
The Nursing Services Department is managed by the director of nursing services.
The director is a registered nurse licensed by this state and has experience in nursing service administration rehabilitation and geriatric nursing. 2.
The directors employed full-time 40 hours per week.
676055 04/29/2026
Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966
During an interview on 04/28/2026 at 1:15 p.m., LVN A said it was a careless mistake administering the B/P medications to Resident #3.
She said she should have held the medications as prescribed by the physician. LVN A said she had been educated and re-educated on administering medications with parameters. LVN A said she should have paid more attention to the directions prescribed for the blood pressure medications. LVN A said Resident #3 had not experienced any adverse signs or symptoms such as decreasing blood pressure or increased heart rate.
During an interview on 04/28/2026 at 1:40 p.m., the ADON said her expectations were for all medications to be administered by physician orders including according to parameters.
She stated this failure could result in resident's blood pressure becoming lower, cause fainting and injury, or resulting in fall with major injuries.
During an interview on 04/29/2026 at 12:00 p.m., the Administrator said his expectations were for all medications to be administered by physician orders.A facility policy titled Administering Medications dated revised April 2019 indicated the following:.
Medications are administered in a safe and timely manner, and as prescribed. 4.
Medications are administered in accordance with prescriber orders, including any required time frames.
676055 04/29/2026
Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966
Based on observations, interviews, and record review, the facility failed to ensure medications were
carts observed (Hall D and Hall C medication carts).
The facility failed to ensure Hall D and Hall C medication cart drawers did not have loose pills in the bottom of the carts.
These failures could place residents at risk of misappropriation of drugs, not receiving prescribed drugs or contaminated medication.
Findings included:During an observation and interview on 04/28/2026 at 2:25 p.m., during review of the Hall D medication cart with the QA nurse, she said she was giving patient medication off this cart today.
The cart review revealed the 2nd drawer contained 18 whole and 5 broken loose unidentified pills.
The QA nurse said the medication cart should be cleaned and no loose pills should be in the drawers.During an observation and interview on 04/28/2026 at 2:39 p.m., during review of the Hall C medication cart with the QA nurse, she said she was giving patient medication off this cart today.
The cart review revealed the 2nd drawer contained 5 whole and 1 broken loose unidentified pill she said the medication cart should be cleaned and no loose pills should be in the drawers.
The QA nurse said the nurses giving medication off the medication cart were responsible for ensuring no loose pills were left on the medication cart and the back up to double check was herself as the QA nurse or DON.
She said she had been working the floor a lot recently and had not been able to do QA duties more than a day or two a week.
The QA nurse said all the nurses had been educated to keep the medication carts clean with no loose pills on the medication cart.
She said the loose pills were overlooked.
The QA nurse said the risk of loose pills on the medication cart was that a resident could run out of their prescription too soon.
During an interview on 04/28/2026 at 2:47 p.m., the ADON said the nurses giving medication off the nurse's medication cart were responsible for ensuring no pills were loose on the medication cart at the end of the shift and the DON and QA nurse were the back up to double check the medication carts.
She said there was no current DON.
She said the nurses were all educated to keep the medication carts clean and remove loose pills.
She said the pills were overlooked.
The ADON said the residents risk if loose pills on the medication cart was a resident could run out of prescribed medication and they would have to be refilled too soon.
During an interview on 04/29/2026 at 12:25 p.m., the Administrator said the nurses providing medication off the medication cart were responsible for ensuring the medication cart was clean with no loose medication. He said the QA nurse and DON were the backup and they were responsible to ensure the medication carts were clean with no loose medication. He said the DON quit last Wednesday (04/22/2026) without notice.The Administrator said the loose medication was overlooked. He said the residents risk of loose medication on the medication cart was that a resident could run out of prescribed medication too soon.
Record review of a facility policy revised April 2019, titled, Storage of Medications indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner.2.
Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.
Only the issuing pharmacy is authorized to transfer medications between containers. 3.
The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
676055 04/29/2026
Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966
rubbish and protected from rodents, roaches, flies and other insects.2.
All utensils, counters, shelves
hinges and fasteners will be kept in good repair.3.
All equipment, food contact surfaces and utensils
necessary and sanitized using hot water and/or chemical sanitizing solutions. 12.
Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy.
Plasticware, China and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze shall be discarded.
Damaged or broken equipment that cannot be repaired shall be discarded.16.
Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.17.
The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas.
Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.
Record review of https://www.fda.gov/media/164194/download?attachment accessed on 3/31/2026 indicated: Chapter 4.
Equipment, Utensils, and Linens Multiuse 4-101.11Characteristics.
Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time.
Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. In addition, some materials can affect the taste of the food being prepared.
Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens.
Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated.
Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food.
Studies regarding the rigor required to remove biofilms from smooth surfaces highlight the need for materials of optimal quality in multiuse equipment.
676055 04/29/2026
Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966
The facility failed to ensure CNAs E and F wore PPE when providing ADL care to Resident #5 who was on enhanced barrier precaution.
These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements.
Findings included:
Record review of Resident #5's face sheet reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of dysphagia (difficulty swallowing).
Record review of Resident #5's quarterly MDS assessment, dated 03/12/26, indicated a BIMS score of 03 indicating Resident #3 was cognitively severely impacted.
Feeding tube was included as one of Resident #5's nutritional approaches.
Record review of Resident #5's care plan dated 02/23/2026 indicated requires a tube feeding.
Interventions included the resident is dependent with tube feeding and water flushes.
Record review of Resident #5's April 2026's physician orders indicated tube feeding only diet.During an observation on 04/27/26 at approximately 9:35 AM, Resident #5 had EBP signage in place and PPE (Personal protective equipment) was noted at the entrance to the resident room.
During an observation on 04/27/26 at approximately 9:40 AM, CNA E entered Resident #5's room to perform ADL care and failed to don (put on) a gown to perform ADL care. Resident #5 was on enhanced barrier precaution due to his gastrostomy tube (a tube directly in abdomen to the stomach to deliver liquids for food, medication and hydration) CNA E cleaned Resident #5's peri-area, changed his brief and CNA F entered the room and helped CNA E pull Resident #5 up in bed.
During the procedure both CNAs bare uniform clothes touched Resident #5's gown and his bed linens.
During an interview on 04/27/26 at approximately 10:00 AM with CNA's E and F both stated they both failed to put on a gown to do ADLs with Resident #5 and his room had sign indicating EBP, they said they knew the resident was on Enhanced Barrier Precaution, but they forgot to put a gown on.
They stated they did not know why they had forgotten. CNA E and F confirmed it was a risk of cross-contamination for the resident and both CNAs said they received infection control training on EBP and PPE.
During an interview with the ADON the infection control preventionist, on 04/28/26 at 10:30 a.m., the ADON stated that a resident with a gastrostomy tube was on Enhanced Barrier Precaution and the staff should wear a gown and gloves while providing care.
She stated the staff were provided with infection control and Enhanced Barrier Precaution training and the risk of not following the EBP increases the risk of cross-contamination. In an interview on 04/29/26 at 11:45 AM the Administrator stated staff in the building had all been trained and retrained on EBP (Enhanced Barrier Precautions). He said those failures could place residents at risk for cross contamination, spread of infection and violated the infection prevention and control requirements.
The Administrator said staff needed to wear a gown and gloves for residents on enhanced barrier precaution to prevent the spread of infection to the residents but also the staff.
The Administrator stated infection control training was provided and skills were checked annually.
Record Review on 04/27/26 of EBP Enhanced Barrier Precautions Policy dated 03/2024 indicated, EBP employs targeted gown, and gloves use in addition to standard precaution during high contact residents care activities when contact precaution do not otherwise apply .
Record
Review of the EBP signage states: When providing care for Dressing, bathing/Showering, transferring, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care any skin opening requiring a dressing.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.