Health inspection·December 20, 2023

F 0636 to the facility; Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 2 of 12 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 676055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 14 residents reviewed for care plans. (Resident #'s 10, 16, 42 and 99). The facility did not develop a comprehensive care plan for Resident #10's diagnosis of PTSD. The facility did not develop a comprehensive care plan for Resident #16's psychotropic medication and did not develop a comprehensive care plan timely for hospice services. The facility did not develop a comprehensive care plan for Resident #42. Resident #99's care plan was not complete and did not reflect current diagnosis. The failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: 1. Record review of physician orders dated December 2023 indicated Resident #10, admitted [DATE], was a [AGE] year-old female with a diagnosis of PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record review of an admission MDS assessment dated [DATE] indicated Resident #10 was cognitively intact and had a diagnosis of PTSD. Record review of a care plan dated 11/14/23 indicated Resident #10 had a mood problem but did not specify if the problem was related to PTSD. The care plan did not include any interventions. During an interview on 12/20/23 at 11:05 a.m., the MDS nurse said Resident #10's care plan did not include a specific focus or goals for PTSD and had no interventions. She said she initiated the care plan on 11/14/23 but had never individualized or completed the care plan because she had overlooked it. She said she last received training on care plans 2 years ago. She said the care plan should have initiated within 21 days of the resident's admission. She said the possible negative outcome could be the resident not receiving the care and services she needed related to her PTSD. During an interview on 12/20/23 at 11:10 a.m., the DON said she was responsible for overseeing care plans. She said she expected care plans to written timely and accurately. She said possible negative outcome of care plans not being completed timely and accurately could be residents not receiving services they needed to help them achieve and maintain their best level of function and health. 2. Record review of a face sheet dated 12/18/2023 indicated Resident #16 was an [AGE] year-old male admitted to the facility on [DATE]. He was admitted for diagnoses including atherosclerotic heart disease (narrowing of the arteries in the heart), major depressive disorder (a mood disorder that effects how you think, feel, and can lead to emotional and physical problems) and calculus of kidney (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 3 of 12 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 676055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 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 and ureter (kidney stones, a buildup of substances in the urine). Level of Harm - Minimal harm or potential for actual harm Record review of a baseline care plan dated 11/17/23 indicated see current MAR and medications and listed Lexapro as a high risk medication. Residents Affected - Some Record review of an admission MDS assessment dated [DATE] indicated Resident #16 had a BIMS score of 00 indicating severely impaired cognition and he had diagnoses of atherosclerotic heart disease, high blood pressure, kidney stones and cancer and received an antidepressant medication. Record review of physician orders dated December 2023 indicated Resident #16 was admitted to hospice services on 12/05/23 for hypertensive heart disease (heart problems that occur because of high blood pressure) and chronic kidney disease (long standing disease of the kidneys leading to renal failure). The orders indicated Resident #16 was prescribed Lexapro (an antidepressant medication) 10 mg daily for mood disorder with a start date of 11/30/23, clonazepam (an antianxiety medication) 0.5 mg two times a day for anxiety (intense, excessive, and persistent worry and fear about everyday situations) with a start date of 12/07/23 and lorazepam (an antianxiety medication) 1 mg every 4 hours for anxiety with a start date of 12/18/23. The orders indicated Resident #16 was prescribed lorazepam 1 mg every 6 hours as needed for anxiety with a start date of 12/06/23. Record review of the electronic medical record on 12/18/23 revealed there was not a comprehensive care plan. Record review of a MAR dated 12/19/23 indicated resident #16 received Lexapro 10 mg daily and clonazepam 0.5 mg two times a day from 12/8/23 to 12/18/23 and was discontinued on 12/18/23. Resident #16 received lorazepam 1 mg every 6 hours as needed on 12/6/23 and 12/7/23. Resident #16 Received lorazepam 1 mg every 4 hours with a start date of 12/18/23 on 12/18/23 and 12/19/23. Record review of a comprehensive care plan initiated 12/19/23 indicated Resident #16 had a hospice care plan initiated 33 days after admission. The EMR did not indicate a plan of care for psychotropic medication use of Lexapro, clonazepam, and lorazepam. There was no documentation to indicate there were interventions or goals in place for the resident's psychotropic medication use. During an interview on 12/19/23 at 1:45 p.m., the MDS nurse said Resident #16 should have had a care plan for his psychotropic medication and did not. She said she just overlooked it. She said the care plan had to be completed by day 21 after admission. The MDS nurse said Resident #16 should have had a care plan for hospice within 72 hours of his readmission on [DATE]. She said she just noticed he had been overlooked and put a care plan in on 12/19/23 but it should have been completed sooner after he readmitted . During an interview on 12/19/23 at 3:07 p.m., the DON said she was responsible for completing the baseline care plans and the MDS nurse was responsible for comprehensive care plans. The DON said Resident #16's psychotropic medication clonazepam, Lexapro and lorazepam and hospice service should have been care planned timely. She said it was just missed. 3. Record review of physician orders dated December 2023 indicated Resident #42, admitted [DATE], was a [AGE] year-old male with diagnoses of dementia, mood disorder and senile degeneration of the brain. The resident was on hospice services and received Seroquel 50 mg one tablet two times a day for senile degeneration of the brain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 4 of 12 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 676055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some Record review of a quarterly MDS assessment dated [DATE] indicated Resident #42 had a diagnosis of dementia, was cognitively moderately impaired, received antipsychotic medications in the last 7 day look back period and received hospice services. Record review of the care plans for Resident #42 indicated a baseline care plan but comprehensive care plan was not initiated. There was no documentation in the paper chart or the electronic chart to indicate the resident had a comprehensive care plan in place. During an interview with the MDS nurse and record review of Resident #42's electronic and paper records on 12/19/23 at 1:43 p.m., the MDS nurse said she was responsible for ensuring the comprehensive care plans were completed. She said Resident #42 did not have a comprehensive care plan completed for the last 2 recertification periods from 04/20/23 to present. She said the care plans were required to be completed by state regulations according to the RAI (user's manual for the MDS). She said the possible negative outcome would be the residents would not receive the services they needed. She said the last time she was trained on care plans was 2 years ago during the RAC-CT certification training. She said she had several responsibilities in the facility and was not able to keep up with completing the residents' care plans. 4. Record review of physician orders dated December 2023 indicated Resident #99, admitted [DATE], was a [AGE] year-old female with diagnoses of major depressive disorder and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath). Record review of the electronic clinical record for Resident #99 indicated the MDS ARD date was 12/14/23 and the MDS was 4 days overdue. There was no MDS documentation found in the electronic or paper clinical record. Record review of a care plan dated 12/18/23 did not indicate Resident #99 had major depressive disorder or chronic obstructive pulmonary disease. There was no documentation to indicate there were interventions or goals in place for the resident's major depressive disorder or respiratory disorder. During an interview and record review of Resident #99's clinical record on 12/18/23 at 10:41 a.m., the MDS nurse said the care plans for Resident #99 were not complete and did not include the resident's chronic obstructive pulmonary disease or her major depressive disorder and should. She said she was responsible for ensuring the care plans were completed in a timely manner. She said the possible negative outcome of an incomplete care plan would be the resident might not receive the care and services she required. During an interview on 12/19/23 at 3:07 p.m., the DON said there should be a care plan initiated for all residents and the care plans should include all care areas/needs. The DON said the MDS nurse was educated on the care plan process. She said the risk of psychotropic medications and hospice services not being care planned timely was staff may not be aware of a resident's needs, interventions needed for care or be aware of goals that need to be completed to meet their quality of life. The DON said her expectation was for care plans to be completed timely and correctly so staff can meet the needs of the residents. During an interview on 12/19/23 at 4:00 p.m., the Administrator said the MDS nurse was responsible for completing care plans. He said his expectation was for all care plans to be completed accurately and timely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 5 of 12 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 676055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of a Care Plan, Comprehensive, Person Centered policy revised March 2022 indicated: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and time frames; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being Event ID: Facility ID: 676055 If continuation sheet Page 6 of 12 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 676055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 14 residents reviewed for urinary catheters. (Resident #27) The facility did not properly secure and position Resident #27's urinary catheter tubing to prevent pulling, tension, or trauma per the facility policy. This failure could place residents with a urinary catheter at increased risk of urinary tract infections or trauma such as accidental removal. Findings included: Record review of physician orders dated December 2023 indicated Resident #27, admitted [DATE], was [AGE] year-old female with a diagnoses of urinary incontinence (Involuntary leakage of urine) and stage IV pressure ulcer (a full thickness tissue loss with exposed bone, tendon, or muscle). The resident had an indwelling urinary catheter (a catheter which is inserted into the bladder to drain urine). Record review of the most recent annual MDS assessment dated [DATE] indicated Resident #27 had severe cognitive impairment, was dependent for all ADLs, and had an indwelling urinary catheter. Record review of a care plan dated 09/13/23 indicated Resident #27 had an indwelling urinary catheter and was at risk for catheter related trauma and infection and did not indicate the catheter should be secured with a leg strap. During an observation and interview on 12/18/23 at 1:45 p.m., revealed Resident #27 was lying in bed while CNA C performed incontinent care. The resident's urinary catheter tubing was not secured. CNA C said the catheter tubing should have been secured to her thigh with a leg strap. CNA C said the resident had pulled her leg strap off on 12/15/23 and she forgot to tell the nurse. CNA C said all residents with catheters in the facility were supposed to have a leg strap in place to keep the catheter tubing from pulling and hurting the resident. During an interview on 12/18/23 at 1:55 p.m., the ADON said all urinary catheter tubing should have a leg strap to secure them and prevent trauma to the resident. She said she had not been aware that Resident #27 did not have a leg strap to secure her catheter. During an interview on 12/20/23 at 11:10 a.m., the DON said facility policy stated that a leg strap should be used for all residents with indwelling catheters. She said Resident #27 should have had a leg strap to secure her catheter tubing. She said nurses applied the leg strap after catheter insertion to secure the tubing and the leg strap should be replaced if the strap was removed or came off. She said leg straps helped to prevent trauma to the resident, infection, and dislodged catheters. She said she was the direct supervisor for all nursing staff and her expectation was all residents with indwelling catheters have a leg strap in place. During an interview on 12/20/23 at 2:04 p.m., the Administrator said he expected nursing to follow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 7 of 12 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 676055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 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 0690 facility policy regarding catheters and leg straps. Level of Harm - Minimal harm or potential for actual harm Record review of a facility policy Catheter Care, Urinary revised September 2014 indicated in part, . Secure catheter with a leg band . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 8 of 12 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 676055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure parenteral care and services were administered consistent with professional standards of practice for 1 of 1 resident reviewed for intravenous fluids. (Resident #19) Residents Affected - Few *The facility failed to administer Resident #19's intravenous antibiotic infusion in accordance with the resident's plan of care. This failure could place residents at risk of not receiving the appropriate IV care and services. Findings included: Record review of Physician orders dated 12/15/23 indicated Resident #19, admitted [DATE], was 79 year's old with diagnosis of endocarditis (an inflammation of the heart's inner lining, usually involving the heart valves). Orders included Vancomycin 1 gram in Sodium Chloride (used to supply water and salt to the body and may be mixed with other medications given by injection into a vein) 250 ml intravenously twice daily for endocarditis. Record review of the MAR initiated 12/16/23 indicated Resident #19 received Vancomycin 1 gram in Sodium Chloride per IV on 12/17/23 at 8:00 p.m. and was initialed by LVN [NAME] given. Record review of MDS and care plan for Resident #19 unavailable due to time frame of being new admission to facility. During an observation and interview on 12/18/23 at 10:45 a.m., revealed Resident #19 had Vancomycin IV solution was hanging from the IV pole at bedside. Solution is labeled as 250 ml to infuse. There was 200 ml remaining in the bag and was not connected to resident. Resident #19 said she had not received morning dose of solution and the bag on pole was from previous nurse. She said she had not administered scheduled morning dose due to awaiting Vancomycin trough level results. (The concentration of drug in the blood immediately before the next dose is administered). LVN A had not noticed the IV bag containing a majority of the medication as she had not been in resident's room that morning. During an interview on 12/18/23 at 10:500 a.m., LVN A verified the remaining Vancomycin IV solution in Resident #19's room was from previous shift. She said she had not administered scheduled morning dose due to awaiting Vancomycin trough lab results. During an observation and interview on 12/18/23 at 11:00 a.m. at Resident #19's bedside, the ADON acknowledged Vancomycin 1 gram was a 250 ml bag which contained 200 ml remaining from previous infusion. She said she expected nursing staff to complete entire infusion of IV antibiotics so residents would receive full beneficial effects of medications. She said risks involved could be resident having complications of not receiving medications as prescribed, could possibly cause resident to return to hospital, and not recovering from illness for which medication is prescribed. During a phone interview on 12/20/23 at 1:45 p.m., LVN B verified she had worked evening shift on 12/17/23 and had infused Resident #19's Vancomycin dosage. She said the settings on the pump indicated the infusion was complete and had been beeping. She said she thought the medication was completed and she had disconnected tubing from Resident #19. She said she was trained in IVs prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 9 of 12 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 676055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few employment at the facility. She said a review was held on IV solutions and infusion pumps following the incident. During an interview on 12/20/23 at 2:00 p.m., DON and ADON said the facility employed 9 full time LVNs and 2 PRN LVNs and all had been trained in IV medications and infusion pumps. Their expectations were for staff to ensure all IV antibiotics were completely infused for residents to receive full beneficial effects of medications. Review of an Antibiotic Stewardship-Staff and Clinician Training and Roles policy dated December 2016 indicated. The facility will educate and train staff and practitioners about the facility antibiotic stewardship program, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 10 of 12 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 676055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. Residents Affected - Many *Food items were not properly labeled with product and expiration date in the refrigerator; and *Food items had gray, hairy substance attached. This failure could place residents who consumed food prepared by staff in the kitchen at risk of cross contamination and food-borne illnesses. Findings included: During the initial tour of the kitchen on 12/18/23 at 9:20 a.m., the following was observed: *One bottle of tartar sauce labeled best by 10/04/23; *One bottle of salad dressing labeled best by 09/06/23; *A container of cream cheese dip with expiration date of 09/18/23; *One covered slice of lemon pie, undated, unlabeled, and with a visible gray hairy substance; *One unlabeled and undated gallon size clear bag containing banana nut bread slices; *Two unlabeled packages of lunch meat with no open date or expiration date; *Four containers of red grapes with copious amounts of a gray hairy substance to bottom area; *Six cartons of blueberries with copious amounts of a gray hairy substance to the bottom area; *Six pineapples, that were soft with copious amounts of a gray hairy substance to the bottom area; and *Six cantaloupes, that were soft, and with multiple blackened areas. During an interview on 12/19/23 at 9:30 a.m., DM said all foods should be properly labeled and dated. He said food that is out of date or expired should be discarded promptly. The foods with mold should have been discarded and not retained in refrigerator. He said he was a certified DM and employees all the kitchen employees had food handler certificates. During an interview on 12/19/23 at 3:35 p.m., the Administrator said there was no excuse for the food items to be expired, not labeled, or with gray substances. He said the DM was responsible for checking stored items in refrigerator for proper storage, including expiration dates and spoilage. He said risks of food borne illnesses was a risk, including salmonella or botulism. His (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 11 of 12 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 676055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 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 0812 expectations were for all food served from the kitchen was to be fresh, labeled and dated. Level of Harm - Minimal harm or potential for actual harm Record review of a Food Receiving and Storage policy dated July 2014 indicated Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation.8. All foods stored in refrigerator or freezer will be covered, labeled, and dated (use by date). Residents Affected - Many Record review of the 2022 Food Code dated 01/18/23 indicated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date. Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers. It is not the intent of the Food Code to require date marking on the labels of consumer size packages. A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color-coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 12 of 12