Inspection·September 5, 2025

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements, in that:The Dietary Supervisor did not have the appropriate certification, education, or qualification to serve as the Director of Food and Nutrition Services.This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.The findings were:During an interview with the Dietary Supervisor on 09/02/2025 at 10:30 a.m., he stated that he was not certified as a Dietary Manager, and that he was enrolled in a course scheduled to begin 09/04/2025. During an interview with the Administrator on 09/05/2025 at 1:15 p.m., the Administrator confirmed the Dietary Supervisor was not yet certified and stated he had expected to receive a citation. The Administrator further stated that the facility did not have a specific policy regarding the Dietary Supervisor's credentials but provided the Job Description. Record review of the Dietary Supervisor Job Description, undated, revealed, In this role you will.Ensure Safety and Compliance.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12. Event ID: Facility ID: 676030 If continuation sheet Page 2 of 5 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 09/05/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 5 residents (Residents #4, #7 and #21) reviewed for infection control, in that: 1. The facility failed to maintain correct infection control when, while providing wound care for Resident #4, LVN C failed to use proper protective equipement. 2. The facility failed to maintain correct infection control when, while observing Resident #7's room, a reusable urinal was seen hang uncovered and hanging from the resident's trash can. 3. The facility failed to maintain correct infection control when, while providing incontinent care for Resident #21, NA A did not change her gloves or wash hands after touching the resident's trash can. These deficient practices could place residents at-risk for infection due to improper care practices. The findings were: 1. Record review of Resident #4's face sheet, dated 09/04/2025, revealed an admission date of 09/11/2024, and, a readmission date of 07/16/2025, with diagnoses which included: Brief psychotic disorder ( Psychiatric condition characterized by sudden and temporary periods of psychotic behavior, such as delusions, hallucinations, and confusion), Dementia (decline in cognitive abilities), Myalgia (muscle pain), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying), Epilepsy (brain condition that causes recurring seizures.), Hemiplagia (Paralysis of one side of the body), Chronic kidney disease (gradual loss of kidney function). Record review of Resident #4's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 11 indicating moderate cognitive impairment. Resident #4 required total assistance and was always incontinent of bowel and bladder. Resident #4 was coded as having a stage 4 pressure ulcer (deep wounds that may impact muscle, tendons, ligaments, and bone). Review of Resident #4's care plan, dated 07/25/2025, revealed a problem of The resident has a pressure ulcer and a goal of The resident's Pressure ulcer will show signs of healing and remain free from infection by review date. Observation on 09/04/2025 at 1:50 p.m., revealed, while providing wound care for Resident #4, LVN C did not wear a gown. Further observation revealed the resident did not have a sign indicating he was on enhanced barrier precaution. During an interview with LVN C, on 09/04/2025 at 1:59 p.m., she stated Resident #4 should be on enhanced barrier precautions because he had a wound, but he was on standard precautions. During an interview with the DON, on 09;04/2025 at 4:30 p.m., she stated Resident #4 should be on enhanced barrier precaution and LVN C should have worn a gown while providing wound care for the resident to prevent infection. The DON further stated the staff had received training on infection control and enhanced barrier precaution within the current year. Review of facility policy, titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug resistant Organisms (MDROs), dated 07/12/2022, revealed EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. 2. Record review of Resident #7's face sheet, dated 09/05/2025, revealed an admission date of 07/05/2025, with diagnoses which included: Spinal stenosis (space around the spinal cord becomes too narrow causing pain and tingling), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure), Pain. Record review of Resident #7's admission MDS, dated [DATE], revealed the resident had a BIMS score of 14 indicating no cognitive impairment. Resident #7 required Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676030 If continuation sheet Page 3 of 5 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 09/05/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete limited assistance and was always continent of bladder and occasionally incontinent of bowel. Observation on 09/04/2025 at 8:25 a.m., revealed during observation of medication administration in Resident #7's room, provided by MA D,a urinal was seen hanging from the outside of the trashcan and unbagged. The urinal had Resident #7's name written on it. During an Interview with MA D on 09/04/2025 at 8:27 a.m., she stated the urinal bottle belonged to Resident #7 and was unbagged while hanging on the trash can. She stated the trash can was considered dirty and the urinal should not have been in direct contact with the trash can because it was a risk for cross contamination and infection for the resident. She stated she received infection control within the current year. During an Interview with the DON on 09/04/2025 at 4:30 p.m., she stated the urinal should not have been hanging from the trash can to prevent cross contamination for the resident. She stated infection control training was provided to the staff, at least, yearly. Review of annual skills check for MA D revealed MA D passed competency for Perineal care/incontinent care and infection control on 01/08/2025. Review of facility policy, titled Toileting, Bedpan/urinal, undated, revealed Clean and store urinal per facility policy During an interview with the Administrator on 09/05/2025 at 11:12 a.m., he stated the facility had no policy on storage of urinal. 3. Record review of Resident #21's face sheet, dated 09/04/2025, revealed an admission date of 02/25/2022, and, a readmission date of 07/08/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Mood disorder (conditions that affect a person's emotional state), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #21's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 09 indicating moderate cognitive impairment. Resident #21 required extensive assistance and was always incontinent of bowel and bladder. Review of Resident #21's care plan, dated 07/09/2024, revealed a problem of Resident will be clean, dry, odor free, will have regular BM (bowel movement) patterns and will be free from S/S (sign and symptoms) of UTI (urinary tract infection) through next review. Observation on 09/04/2025 at 2:11 p.m. revealed while providing incontinent care for Resident #21, NA A, after washing her hands and putting gloves on, touched the trash can with her gloved right hand. She, then, touched the clean wipe with the same right hand without changing her glove or washing her hands. During an interview on 09/04/2025 at 2:20 p.m. with NA A, she stated, she had touched the trash can with her gloved hand and did not change gloves or wash her hands before touching the clean wipe. She stated the trash can was considered dirty and she should have changed her gloves to prevent infection for the resident. She stated receiving infection control within the current year. During an interview with the DON on 09/04/2025 at 4:20 p.m., she stated the staff should have changed gloves and wash her hands prior to start the care to prevent cross contamination and infection to the resident. She stated infection control training was provided for the staff at least yearly and their skills were checked annually. Review of annual skills check for NA A revealed NA A passed competency for Perineal care/incontinent care and infection control on 07/31/2025. Review of Facility policy, titled Hand Hygiene, undated, revealed you may use alcohol-based hand cleaner or soap/water for the following: [ .] after handling soiled equipment or utensils Event ID: Facility ID: 676030 If continuation sheet Page 4 of 5 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 09/05/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents, staff and the public in 1 of 3 (South Wing) shower rooms reviewed, in that: The toilet in the South Wing shower room was loosely affixed to the floor. This deficient practice could place residents who utilized the toilet in the South Wing shower room in danger of falling. The findings were: Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents, staff and the public in 1 of 3 (South Wing) shower rooms reviewed, in that: The toilet in the South Wing shower room was loosely affixed to the floor. This deficient practice could place residents who utilized the toilet in the South Wing shower room in danger of falling. The findings were: Observation of the South Wing shower room on 09/02/2025 at 1:42 p.m. revealed that the toilet was loosely affixed to the floor and was able to be moved approximately three inches away from center. During an interview with RN E on 09/02/2025 at 1:45 p.m., RN E confirmed the toilet was loosely affixed to the floor and was able to be moved approximately three inches away from center. RN E confirmed that this could potentially cause residents who utilized the toilet to fall and stated she would alert the Maintenance Department. During an interview with the Administrator on 09/05/2025 at 1:15 p.m., the Administrator stated that he agreed the loose toilet could potentially cause residents who utilized it to fall and provided documentation of the Maintenance repair request, dated 09/02/2025. The Administrator stated the facility did not have a specific policy pertaining to the circumstance. Observation on 09/05/2025 at 1:00 p.m. revealed the toilet had been repaired. Event ID: Facility ID: 676030 If continuation sheet Page 5 of 5