Inspection·July 14, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to develop and implement policies and procedures for screening through the employee misconduct registry to determine whether the individual is designated as unemployable for 10 of 18 staff (The DS, AD, MA A, CNA D, CNA E, MA F, [NAME] G, LVN I, RN J, and MDS Coordinator) reviewed for employment registry screenings, in that: Residents Affected - Some The DS, AD, MA A, CNA D, CNA E, MA F, [NAME] G, LVN I, RN J, and MDS Coordinator did not have current employment registry screenings. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings were: Record review of the staff roster provided on 07/11/2023 by the facility revealed a hire date of 07/01/2022 for the DS, AD, MA A, CNA D, CNA E, MA F, [NAME] G, LVN I, RN J, and MDS Coordinator. In an interview with the HR Coordinator on 07/13/2023 at 10:07 a.m., the HR Coordinator revealed when the current corporation acquired the facility all staff were given a new hire date as of the date of acquisition. The HR Coordinator further revealed EMRs (employee misconduct registry) were run for all staff the month prior to the acquisition. Record review of the HR background screenings file, with the HR Coordinator present revealed the last annual Employee Misconduct Registry (EMR) check for the DS was completed on 06/01/2022. Record review of the HR background screenings file, with the HR Coordinator present revealed the last annual Employee Misconduct Registry (EMR) check for LVN I was completed on 06/18/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 10:28 a.m., the HR Coordinator revealed she was unable to find an annual EMR check for MA A, CNA D, CNA E, MA F, [NAME] G, AD, RH J, and the MDS Coordinator, however stated they all would have had one completed in June 2022 prior to the acquisition. She further stated all EMRs are currently checked based on each employee's annual competency renewal and the check in June 2022 threw off that schedule. In an interview with the AIT and RCN on 07/13/2023 at 5:26 p.m., the AIT confirmed the HR Coordinator had revealed the EMRs had not been completed due to the HR Coordinator's scheduling process. Record review of the facility's policy titled, Employment Eligibility, revised 09/20/2019, revealed, This facility completes a comprehensive background check prior to offer of employment, annually following your hire and as needed for reported concerns that could impact the resident care or facility liability. Record review of the facility's policy titled, Abuse/Neglect, revised 3/29/18, revealed, Procedure. A. Screening: Criminal History and Background Checks. 7. Employees will be screened for abuse, neglect, and exploitation of the elderly by accessing the Employee Misconduct Registry . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676030 If continuation sheet Page 2 of 10 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 676030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Oak Nursing and Rehabilitation 101 S Lancaster Moulton, TX 77975 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that an assessment was completed for residents within 14 days after a significant change in the resident's status for 1 of 12 residents (Resident #10) reviewed for MDS assessments, in that: Residents Affected - Few The facility failed to complete a Significant Change MDS for Resident #10 within 14 days after the resident was admitted to hospice services. This failure could place residents admitted to hospice services at-risk of not having their individual needs met. The findings were: Record review of Resident #10's face sheet, dated 07/13/2023, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included: hypertensive heart disease without heart failure (includes a number of complications of high blood pressure that affect the heart), dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle weakness, difficulty in walking and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately or following directions). Record review of Resident #10's Care Plan, revised on 06/06/2023, did not reveal a focus for hospice services. Record review of Resident #10's electronic MDS record revealed the resident did not have a Significant Change MDS initiated or completed. Record review of Resident #10's electronic medical record Order Summary Report of Active Orders as of 07/13/2023, revealed an order Admit to Hospice B with a start date of 06/06/2023. During an interview with MDS Coordinator on 07/12/2023 at 2:12 p.m., the MDS Coordinator confirmed the significant change MDS should have been completed withing the 14 days and stated, We had several admissions and discharges and payor changes during that time. I will get it scheduled now. During an interview with the Regional Compliance Nurse on 07/12/2023 at 4:25 p.m., the RCN confirmed the significant change MDS should have been completed and stated the facility follows the RAI manual as policy for completing resident assessments. Record review of CMS's RAI Version 3.0 Manual, dated 10/2019, page 2-23 and 2-24 revealed a Significant Change in Status Assessment is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on a resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676030 If continuation sheet Page 3 of 10 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 676030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Oak Nursing and Rehabilitation 101 S Lancaster Moulton, TX 77975 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 16 residents (Residents #10 and #17) for care plan revisions in that: 1. The facility failed to ensure Resident #10's care plan was revised to include hospice services. 2. The facility failed to ensure Resident #17's care plan was revised to include may sleep in another room after an altercation with their roommate (Spouse) on 7/08/23. These failures could place residents at risk of not receiving care according to their needs. These findings were: 1. Record review of Resident #10's face sheet, dated 07/13/2023, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included: hypertensive heart disease (includes a number of complications of high blood pressure that affect the heart), dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle wasting and atrophy (loss of muscle tissue), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately or following directions). Record review of Resident #10's electronic medical record revealed as of 07/14/2023 a significant change MDS had not been completed related to Resident #10's hospice admission. Record review of Resident #10's care plan, last review date 06/06/2023, revealed no focus area for hospice care. Record review of Resident #10's electronic medical record Order Summary Report of Active Orders as of 07/13/2023, revealed an order on 06/06/2022 for: Admit to [Hospice Company]. In an interview with the MDS Coordinator on 07/12/23 at 02:12 p.m., the MDS Coordinator confirmed she was responsible for updating care plans and that Resident #10's care plan had not been updated. The MDS Coordinator stated during the time the revision was due the facility had several admissions and discharges which may have caused her to overlook the revision. 2. Record Review of Resident #17's admission record, dated 7/14/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis to include: [Major Depressive Disorder] persistently low or depressed mood, decreased interest in pleasurable activities. [Cerebral Infarction] occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts. [ Muscle Wasting] A weakening, shrinking, and muscle loss caused by disease or lack of use. Review of the progress note, dated 7/9/23, revealed that Resident #17 had an altercation with their roommate (spouse), resulting in Resident # 17 spending the night in another room per her request. Review of Resident #17's Care Plan, last revised on 01/24/23, did not reveal a focus area for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676030 If continuation sheet Page 4 of 10 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 676030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Oak Nursing and Rehabilitation 101 S Lancaster Moulton, TX 77975 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 0657 Resident #17 may spend the night in another room after Altercation with a spouse if it were to occur again. Level of Harm - Minimal harm or potential for actual harm Review of the facility investigation dated 7/9/2023 revealed Resident #17 had an altercation with their spouse roommate and that Resident #17 requested to spend the night in another room. Residents Affected - Few Interview and observation on 07/13/2023 at 01:30 PM with Resident #17, noted no visible injuries. Resident # 17 stated she would like a spare bedroom to spend the night when her spouse has alterations as this has been his common behavior, which he has demonstrated over the last 68 + years of marriage. Resident #17 stated in the morning it's like nothing happened. Interview on 07/13/23 at 04:39 PM the MDS Coordinator confirmed she was responsible for updating care plans, and she stated she had not updated Resident #17 's care plan as no further altercations had occurred and stated Resident #17's spouse was her roommate'. The MDS coordinator stated it was a one-time occurrence and Resident #17's spouse was only in the facility for a temporary skilled stay. The MDS coordinator stated the risk of not updating the care plan was possibly risking not all team members being aware. Interview on 7/13/2023 at 515PM the DON stated she was new at her position and that the MDS coordinator would have more information regarding the care plan. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed, 11. Assessments of residents are on-going and care plans are revised as information about the residents and residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: (a) when there has been a significant change in the resident's condition; (b) when the desired outcome is not met; (c) when the resident has been readmitted to the facility from a hospital stay; and (d) at least quarterly, in conjunction with the required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676030 If continuation sheet Page 5 of 10 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 676030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Oak Nursing and Rehabilitation 101 S Lancaster Moulton, TX 77975 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 (Resident # 12) reviewed for hospice services. 1. The facility failed to obtain Resident #12's most recent hospice plan of care, signed hospice election form, and a physician's re-certification of the terminal illness. This failure could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #12's face sheet, dated 07/14/23, revealed a [AGE] year old female resident admitted to the facility on [DATE] with diagnoses: [Ascites] is a buildup of fluid in your abdomen. [Malignant neoplasm]is another term for a cancerous tumor, and [Parkinson's disease] is a progressive disorder that affects the nervous system. Record review of Resident #12''s Quarterly MDS dated [DATE] revealed a BIMS of 15, which indicated Intact cognitive response. Further review revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility. Record review of Resident #12''s comprehensive care plan initiated on 02/04/23 revealed a focus area for end-of-life care with the name and number of the hospice agency. Interventions included visits from the following hospice interdisciplinary team members, RN, CNA, SW, and Spiritual support. Record review of Resident #12's electronic medical record active orders as of 07/14/2023 revealed an order on 02/04/2023, Admit to [name of facility] under [Hospice A, MD name] attending. Record review of Resident #12''s hospice binder at the nurse's station, revealed a hospice plan of care dated 04/10/2023, a hospice election form not signed by the resident/responsible party, and a physician's re-certification of the terminal illness not signed by the physician. Documentation by specific interdisciplinary hospice staff was in the hospice binder. Record review of the facility's hospice services agreement with Hospice A, with effective date, April 22, 2011, revealed, in 3.1.16 coordination of Services. Hospice shall: (c) provide facility with the following information specific to each Hospice Patient residing at Facility: (i) the most recent Plan of Care; (ii) the hospice election form and any advanced directives; (iii) the Physician certification and recertification(s) of the terminal illness; and 3.3.1 Development and implementation of Joint Plan of Care. When a facility resident is authorized by Hospice for admission to the Hospice Program, and the Facility admits a Hospice Patient to the Facility, Hospice and Facility shall jointly develop and agree upon the Patient's Joint Plan of Care. Hospice and Facility each shall maintain a copy of each Patient's JPOC in the respective clinical records maintained by each party. Hospice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676030 If continuation sheet Page 6 of 10 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 676030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Oak Nursing and Rehabilitation 101 S Lancaster Moulton, TX 77975 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Facility each shall designate a registered nurse responsible for coordinating the implementation of the JPOC for each Patient. Record review of Resident #76's hospice binder at the nurse's station, revealed another hospice election form, dated 02/11/2023, signed by resident's family member when Resident #76 was receiving hospice services at home. Record review of the facility's hospice services agreement with Hospice Company , with effective date, February 7, 2020, revealed, in 2.4 (d) As frequently as required by the Hospice Patient's condition, but no less frequently than every fifteen (15) days, the Hospice Interdisciplinary Committee (in collaboration with the patient's Attending Physician) shall review, revise and document the Hospice Plan of Care to include information from updated patient assessments, and progress toward outcomes and goal specified in the Hospice Plan of Care. All such updates shall be communicated to Nursing Home. Further review revealed in 2.5 Hospice Services (a) Coordination of Services. (ii) Hospice shall provide Nursing Home with the following information: (a) the most recent individualized Hospice Plan of Care for each Hospice patient; (b) the Patient's election form for Hospice Services and any advance directives specific to each patient; (c) each Hospice Patient's physician certification and recertification of terminal illness. In an interview with the DON on 07/13/2023 at 10:45 a.m., the DON revealed MDS nurse was the staff person responsible for coordinating with the hospice agencies and ensuring all hospice documentation was in the resident's electronic record. In an interview with the DON on 07/13/2023 at 11:45 a.m., the DON revealed the facility must receive a hospice election form when a resident was admitted to hospice in order to bill for services. The DON further revealed the form would have to be fully completed and signed because the facility would have to know if the resident or family had chosen to elect or cancel the hospice benefit. DON stated she does not know why the needed information was not in the Hospice binder; she stated she is responsible for Auditing Hospice Binders to ensure that all needed information is included however does not know why it was missed; she stated the resident risked not having the Hospice agency and Nursing staff not communicating effectively by information needed not being in the chart. In an interview with MDS Nurse on 07/13/2023 at 11:12 a.m., MDS Nurse revealed she was assigned to coordinate with hospice agencies to ensure hospice agencies email over their documentation, and she uploads what is sent to the resident's electronic record and places necessary documentation in Hospice binder. MDS Nurse could not provide the documents needed for Resident #12 and stated she would call the agencies and ask them to bring any documentation being requested to the facility. Record review of the facility's policy titled, End of Life Hospice Type Care & Coordination, dated 2/7/2007, revealed, To provide supportive care for residents and their families during the end stages of life by enabling them to participate in interactions of their choice in a supportive environment with the assistance of compassionate caregivers and interdisciplinary teams. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676030 If continuation sheet Page 7 of 10 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 676030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Oak Nursing and Rehabilitation 101 S Lancaster Moulton, TX 77975 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could place residents at risk for injury or improper care due to a lack of training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator had not received training in the QAPI program. In an interview with the AIT and RCN on 07/13/2023 at 4:36 a.m., the RCN revealed she was not aware QAPI was part of the mandatory training. She stated the facility will be transitioning to a new web-based learning platform and QAPI would be included. Record review of the facility's policy titled, Employee Education Program, dated 09/20/2019, revealed, All employees regardless of status or classification are required to complete mandatory training as defined by Federal, State and company policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676030 If continuation sheet Page 8 of 10 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 676030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Oak Nursing and Rehabilitation 101 S Lancaster Moulton, TX 77975 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 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide the required compliance and ethics training for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training requirements, in that: Residents Affected - Some The facility failed to ensure compliance and ethics training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator had not received the required compliance and ethics training. In an interview with the AIT and RCN on 07/13/2023 at 4:36 a.m., the RCN revealed she was not aware ethics was part of the mandatory training. She stated the facility will be transitioning to a new web-based learning platform and ethics would be included. Record review of the facility's policy titled, Employee Education Program, dated 09/20/2019, revealed, All employees regardless of status or classification are required to complete mandatory training as defined by Federal, State and company policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676030 If continuation sheet Page 9 of 10 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 676030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Oak Nursing and Rehabilitation 101 S Lancaster Moulton, TX 77975 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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator had not received the require mandatory effective behavioral health. In an interview with the AIT and RCN on 07/13/2023 at 4:36 a.m., the RCN revealed she was not aware behavior health was part of the mandatory training. She stated the facility will be transitioning to a new web-based learning platform where it would be included. Record review of the facility's policy titled, Employee Education Program, dated 09/20/2019, revealed, All employees regardless of status or classification are required to complete mandatory training as defined by Federal, State and company policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676030 If continuation sheet Page 10 of 10