Health inspection·October 23, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some abusing others sexually or public sexual acts identified. She required assistance for self-care and was independent with transfers and required supervision with ambulation. Record review of Resident #6's care plan with a target date of 09/08/2025 indicated Resident #6 had an impaired cognitive function/dementia or impaired thought process. Interventions included clear communications, to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #6 had an updated or revised care plan for receiving sexual behaviors from another resident on 03/12/2025. Resident #1Record review of Resident #1's face sheet, dated 10/20/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), dementia (loss of cognitive functioning), and impulse disorder (conditions that involve difficulties in controlling emotions and behaviors, particularly those that are aggressive or antisocial). Record review of Resident #1's quarterly MDS Assessment, dated 09/09/2025, indicated he was severely impaired cognitively with a BIMS score of 6. He had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurring 1 to 3 days during the 7-day look back period. He required supervision assistance for self-care and mobility. Record review of Resident #1's care plan with a revision date of 06/17/2025 indicated Resident #1 had psychosocial wellbeing problems to include disorganized thinking, hallucinations, delusion, verbal aggression, easily annoyed, concentration problems, lack of energy, sleep problems, resist care and wandering related to schizophrenia and insomnia with interventions to include encourage participation from resident who depends on others to make own decision, psych services with continue to monitor patient for changes in mood/behaviors and medication management, and support the resident to set realistic goals. The care plan did not indicate Resident #1 had an updated or revised care plan for sexual behaviors on 03/12/2025, 03/16/2025, 06/30/2025, and 08/20/2025. 1. Record review of Resident #6's progress note/behavior note dated 03/12/2025 indicated DS C alerted LVN K to check on Resident #1 & #6 who was both sitting in dining room. LVN K observed Resident #6's hand down the front of Resident #1's pants and Resident #1 was holding Resident #6's hand and arm in place when LVN K told Resident #6 to remove her hand from Resident #1's pants, Resident #1 would not let go of Resident #6's arm. LVN K had to manually remove Resident #6's hand which was wrapped around Resident #1's penis. Record review of Resident #1's progress note/behavior note dated 03/12/2025 indicated DS C alerted LVN K to check on Resident #1 & #6 who was both sitting in dining room, LVN K observed Resident #6's hand down the front of Resident #1's pants and Resident #1 was holding Resident #6's hand and arm in place when LVN K told Resident #6 to remove her hand from Resident #1's pants, Resident #1 would not let go of Resident #6's arm. LVN K had to manually remove Resident #6's hand which was wrapped around Resident #1's penis. Resident #1 became angry yelling at the nurse to leave them alone. Unable to interview Resident #6 she no longer resides at the facility. During an interview on 10/21/2025 at 2:45 p.m. with DS C, he said on 3/12/2025 he was in the secure unit and observed Resident #1 and Resident #6 sitting in the common dining area., Resident #6 had her hand down Resident #1's pants, he immediately notified the CN/LVN K which was nearby, but her back was to Resident #1 and #6 because she was interacting with other residents. He said LVN K intervened and asked Resident #6 to remove her hand from Resident #1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 2 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some pants. He said Resident #1 got upset and yelled at LVN K, but LVN K removed Resident 6's hand from Resident #1's pants and removed Resident #6 from the situation. He said what he observed was inappropriate touching/sexual abuse and he reported the allegation immediately to the charge nurse/LVN K. An attempted telephone interview on 10/20/2025 at 5:10 p.m. and 10/21/2025 at 12:27 p.m. with LVN K, was unsuccessful Resident #2 Record review of Resident #2's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), hypertension (condition in which the force of the blood against the artery walls is too high) and diabetes type 2 (a chronic condition that affects the way the body processes blood sugar). Record review of Resident #2's admission MDS Assessment, dated 07/01/2025, indicated she sometimes was able to make self-understood and sometimes understood others. She was not assessed for the brief interview for mental status because she rarely/never understood. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, but no behaviors symptoms identified within the 7-day look back period. She required moderate assistance and supervision assistance for self-care and supervision with mobility. Record review of Resident #2's care plan revision dated 07/30/2025 indicated Resident #2 had impaired cognitive function/dementia or impaired thought processes r/t dementia. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #2 had an updated or revised care plan for receiving sexual behavior from another resident on 08/20/2025. 2. Record review of Resident #1's progress note/behavior note dated 03/16/2025 authored by LVN K indicated CNA notified LVN K that Resident #1 entered his room while she was assisting roommate back to bed and was observed by CNA and roommate masturbating, CNA requested Resident #1 to stop, and he became angry and screamed at the CNA. CNA was able to redirect Resident #1. Record review of Resident #1's progress note/health status note dated 06/30/2025 authored by LVN K indicated another resident came and reported to staff that Resident #1 was in the middle of the common area and had exposed his private area and was holding it. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated NP and RP was notified of Resident #1's sexual behaviors and received a new order to send Resident #1 to behavioral center and start Depo-Provera (a female hormone used in men to suppress testosterone production, which can lead to decrease in sexual drive and aggressive behaviors) 150mg/ml and one on one supervision was initiated. Record review of Resident #2's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of the facility's PIR, dated 08/28/2025, incident category as abuse signed by the ADON on 08/28/2025. The PIR indicated the incident occurred on 08/20/2025 at 4:30 p.m., in the dining room of the secure unit. The PIR indicated CNA A witnessed Resident #1 walked up behind Resident #2, put his hands on her shoulders and was rubbing his private area on her backside. Residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 3 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some were separated immediately, RN D performed a head-to-toe assessment on both residents, no injury. Resident #2 stated he didn't hurt me. Resident #1 stated I'm sorry. Investigation summary indicated CNA A intervened immediately and told Resident #1 to stop and he immediately walked off. Resident #2 was unable to be interviewed due to advanced Dementia. Resident #1 stated yes, I rubbed her back, and I shouldn't have and stopped when CNA told me to. Provider actions taken post-investigation was due to eyewitness and Resident #1 admitting to the situation, the allegation was confirmed. Resident #1 was immediately placed on 1:1 supervision with a new medication prescribed for Depo-Provera and referred to a behavioral hospital. Resident #1 remained on 1:1 monitoring until transferred to behavioral hospital on [DATE]. During an observation and interview on 10/20/2025 at 11:30 a.m., Resident #1 was observed ambulating independently in the secure unit hallways and in the outdoor secure area. Resident #1 interviewed regarding the sexually behaviors/allegations, he stated I'm sorry. He would then start asking about needing assistance with banking accounts, financial records and when his family member was arriving at the facility. During an observation and attempted interview on 10/20/2025 at 11:40 a.m., Resident #2 observed sitting in a chair close to dining table and preparing for lunch to be served. Resident #2 with no signs of abuse or fear identified. Resident #2 did not answer interview questions appropriately. During an interview on 10/20/2025 at 3:00 p.m., LVN E said she did not routinely work in the secure unit, she was covering a shift, but she was familiar with the residents on the secure unit. She said she is made aware during shift reports of any resident incidents, behaviors, monitoring required and task due. She said she was not aware of any specific residents on the secure unit currently requiring 1:1 monitoring but due to the cognitive impairment of most of the secure unit residents they must be monitored closely. She said the secure unit has a designated nurse, three CNAs and assistance from restorative aide and activity aide routinely during day shift, so plenty of staff for monitoring. She said as a charge nurse if an abuse allegation is reported to her, she responded immediately, separating involved individuals, and completed head to toe assessment, notified RP, MD, DON, Administrator/AC, hospice (if applicable) and followed orders as received. LVN E said she is aware of Resident #1's sexual behaviors but has not witnessed these behaviors during her assigned shifts. She said Resident #3 did have a history of aggressive behaviors with Resident #4 & #5; Resident #4 has been moved off the secure unit so the two no longer have contact. She said Resident #3 and #5 both still reside on the secure unit and staff attempt to prevent any altercations or interactions between the two. She said they are both up in their wheelchairs in the hallways and that is when the incidents occur due to one being in the path of the other, but staff try to intervene or redirect prior to that occurring. During an interview on 10/20/2025 at 3:30 p.m., CNA A said on 08/20/2025 she was exiting the nurse's office and observed Resident #1 standing behind Resident #2 with his hands on her shoulders moving down to her waist and was rubbing his private area on Resident #2 backside (humping). She said both residents were fully clothed, and she told Resident #1 to stop and immediately hollered for the nurse or assistance. CNA A said she and the nurse separated Resident #1 and Resident #2. CNA A said she was aware that Resident #1 had a history of sexual behaviors with exposing himself, inappropriate touching and masturbating but this was the first incident she witnessed the behaviors involving another resident. She said the incident witnessed was sexual abuse and she reported the incident immediately to the CN/RN D. She said all abuse or neglect allegations are to be reported to CN immediately after intervening and keeping involved residents safe. During an interview on 10/20/2025 at 4:30 p.m., Resident #2's family member said she was notified by facility staff and was aware of the sexual behavior allegation that occurred to Resident #1 back on 08/20/2025. She said she was initially shocked about the incident and felt Resident #2 would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 4 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some upset about the incident. She said she understood that most of the residents on the secure unit were cognitively impaired and unaware of their actions. She said she was not aware of who the perpetrator was or if he still resided at the facility but she noticed after the incident that Resident #2 would track the younger Caucasian male on the secure unit with her eyes when he got in close perimeter to them but that could be her being protective of a family member. She said she was notified by the facility of incidents and had not noticed any signs of abuse or other fearful behaviors from Resident #2 during unannounced routine visits. An attempted telephone interview on 10/20/2025 at 5:00 p.m. and 10/21/2025 at 9:37 a.m. with RN D, was unsuccessful. During an interview on 10/20/2025 at 5:30 p.m., the DON said she was not the active DON during the incident on 03/12/2025 between Resident #1 and #6 but was active DON and aware of the incident/allegation on 8/20/2025 between Resident #1 and #2 sexual abuse allegations. She said on 08/20/2025 she was made aware of the sexual behaviors from Resident #1, and he was placed on 1:1 monitoring, RP and MD notified, and new orders received for Depo-Provera injection and referral to behavioral hospital. She said both Resident #1 & #2 were assessed by staff with no injuries reported. She said Resident #1 was on 1:1 monitoring until he was transferred to behavioral hospital. She said abuse allegations are to be reported to the Administrator/AC within 24 hours. During an interview on 10/20/2025 at 5:50 p.m., the Administrator said he was aware of the incident between Resident #1 and Resident #6 on 03/12/2025 and it was not reported to the state agency because he considered the incident to be consensual because Resident #1 did not want Resident #6's hand removed. He was unable to provide evidence of how Resident #6 hand got to the location or written consent from responsible party of Resident #1 or Resident #6 due to lack of cognitive ability to consent to consensual sexual contact. He said the incident with sexual behaviors between Resident #1 and #2 on 08/20/2025 was reported to him and he reviewed the incident and identified sexual abuse allegation and reported it to the state agency late. During an observation of the secure unit on 10/21/2025 at 11:20 a.m. to 12:00 noon, 14 residents were observed sitting in the TV/common area watching TV and interacting with staff. Residents were well groomed and appropriately dressed. No indication or signs of abuse or neglect. Residents were transitioned to the dining room for lunch to be served. Observed Resident #2 closely - no indication that she was visually tracking another resident or staff member; she remained in chair with eyes closed and aroused when staff spoke and interacted with her. Resident #3Record review of Resident #3's face sheet, dated 10/20/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #3's quarterly MDS Assessment, dated 06/20/2025, indicated she was able to make herself understood and understood others. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 4 to 6 days within the 7-day look back period. She required moderate to supervision assistance for self-care and was independent with mobility using a manual wheelchair, required supervision to walk. Record review of Resident #3's care plan revision dated 10/23/2024 indicated Resident #3 had behavior/mod issues and had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with agitation and aggression. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 5 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #3 had an updated or revised care plan for aggressive behaviors on 04/18/2025, 04/19/2025, 04/20/2025, 05/14/2025, 05/18/2025, 05/27/2025, and 06/11/2025. Resident #4 Record review of Resident #4's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's annual MDS Assessment, dated 05/05/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and moderately impaired cognitively for daily decision making. She had no indications of behaviors of physical or verbal symptoms directed towards others during the 7-day look back period. Record review of Resident #4's care plan revision dated 01/01/2025 indicated Resident #4 had impaired cognitive function/dementia or impaired thought processes. Interventions included communicating, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, providing homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #4 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 04/19/2025. 3. Record review of Resident #4's progress note/health status note dated 04/19/2025 authored by LVN K indicated Resident #4 was sitting in dining room, when Resident #3 became angry and hit Resident #4 on top of the right hand with wrapped silverware. No injury noted RP notified. Record review of Resident #4's progress note/health status note dated 04/22/2025 authored by RN D Resident #4 continues day 3 follow-up status post being hit with a spoon on her right hand posteriorly. No complaints of pain or s/s of pain were observed. Resident doesn't remember being hit. No signs of bruising observed. Record review of Resident#3's progress note/behavior note dated 04/18/2025 authored by LVN K indicated Resident #3 attempted to hit another resident who was wheeling themselves down hallway in wheelchair, resident angrily stated that that lady is following me nurse redirected patient and told resident she was not being followed that she was going in the opposite direction of the other resident. Record review of Resident#3's progress note/behavior note dated 04/19/2025 authored by LVN K indicated Resident #3 was angry started screaming at 2 other residents CNA F attempted to redirect Resident #3; she remained angry screaming and a few minutes later Resident #3 picked up wrapped silverware from the table and hit Resident #4 on the hand. Record review of Resident #3's progress note/behavior note dated 04/20/2025 authored by LVN K indicated Resident #3 telling other residents that they are trash and that she will call the cops on them staff unable to redirect, resident becomes angry and screams at staff. Record review of Resident #3's progress note/health status note dated 04/22/2025 authored by RN D Resident #3 continues day 3 follow-up status post hitting another resident with a spoon. Resident does not remember hitting anyone. She continues to have episodes of verbal aggression, requiring redirection at times. UA was collected for analysis due to increased aggression. During an observation of the secure unit on 10/20/2025 at 11:25 a.m., Resident #3 was observed up in wheelchair well-groomed with no foul odor. She was maneuvering herself up and down the halls independently. She did not answer interview questions appropriately. During an observation on 10/20/2025 at 1:25 p.m., Resident #4 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 6 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some observed resting in bed. She was well groomed with no foul odor. She denied abuse by shaking her head no and knotted her head yes when ask is she felt safe at the facility and was pleased with care. During an interview on 10/21/2025 at 2:45 p.m., RN G said she works the night shift on the secure unit. She said Resident #3 did have a history of aggressive behaviors and usually if behavior continued that it could be an indicator of an UTI and she would collect a urinalysis. She said she does not recall witnessing or being involved in incidents with Resident #3 but provided follow up assessments or notes after the incident occurred. She said if she was notified of an abuse allegation, she would make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator. She said if she witnessed a resident being abused that she would intervene and remove the abuser and keep the resident safe, notify the AC and if staff involved send staff member home. During an interview on 10/22/2025 at 8:00 a.m., CNA F said she worked on the secure unit as a CNA and she had provided care for Resident #3, she said the day of the incident between Resident #3 and Resident #4; Resident #3 was screaming at other residents and she had redirected her and later returned her to the dining room to prepare for supper. She went to get a dinner tray and Resident #3 grabbed the wrapped silverware from the table and hit Resident #4 on top of the right hand. She said she just turned her back long enough to get tray from cart, and she grabbed wrapped silverware and hit Resident #4. She said after the incident Resident #3 was separated from other residents. She said Resident #3 had a history of aggressive behaviors and she usually could be redirected before behaviors escalated. She said Resident #3 usually starts yelling or screaming prior to physical aggression and staff intervene to prevent physical aggression or trigger. She said Resident #4 was moved off the unit so there were no other incidents between her and Resident #3. She said Resident #3 and Resident #5 have a history of altercations because they wheel themselves around the unit and staff try to watch them and make sure that they do not have incident or altercations. Resident #7Record review of Resident #7's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included dementia (loss of cognitive functioning), diabetes (a chronic condition that affects the way the body processes blood sugar), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #7's quarterly MDS Assessment, dated 09/04/2025, indicated she was able to make herself understood and understood others. She had a BIMS score of 02 indicating that she was severely impaired cognition. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) daily within the 7-day look back period and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 4 to 6 days (but not daily) within the 7-day look back period. Record review of Resident #7's care plan revision dated 07/08/2024 indicated Resident #7 had impaired cognitive function/dementia or impaired thought processes. Interventions included administering medications as ordered, communicating with resident/family/caregivers regarding resident's capabilities and needs and consulting psychiatric/psychogeriatric is indicated. The care plan did not indicate Resident #7 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 05/14/2025 and 05/18/2025. 4. Record review of Resident #7's progress note/behavior note dated 05/14/2025 authored by indicated just prior to breakfast, Resident #7 had coffee thrown on her by Resident #3. Resident #7 in return struck Resident #3 on the side of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 7 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete head with her fist. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. No indication that the physical and verbal altercation was reported to the abuse coordinator. Record review of Resident #3's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #3 threw coffee on Resident #7, called her names and threatened to kill her. Resident #7 struck Resident #3 on the side of her head with her fist. The witnesses to the situation said Resident #3 was not provoked. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. No indication that the physical and verbal altercation was reported to the abuse coordinator. 5. Record review of Resident #7's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 stating she would beat her ass, LVN K was able to intervene and separate the residents. No indication that the verbal altercation was reported to the abuse coordinator. Record review of Resident #3's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 calling her an evil bitch LVN K was able to intervene and separate the residents. No indication that the verbal altercation was reported to the abuse coordinator. During an observation on 10/20/2025 at 11:00 a.m., Resident #7 was well groomed, and appropriately dressed. Resident #7 was lying in her bed resting. She was easily aroused but did not respond appropriately to interview questions. Resident #7 with no signs of abuse or fear of staff identified. An attempted telephone interview on 10/20/2025 at 5:10 p.m. and 10/21/2025 at 12:27 p.m. with LVN K, was unsuccessful. 6. Record review of Resident #3's progress note/behavior note dated 05/27/2025 authored by LVN H indicated Resident #3 punched an unidentified resident in her chest. When asked why and what the other resident done to her, she stated, I don't remember, I just have so much anger inside. Resident #5Record review of Resident #5's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant i Event ID: Facility ID: 676055 If continuation sheet Page 8 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator for immediate intervention and all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 7 of 10 residents (Resident #1, #2, #3, #4, #5, #6, and #7) reviewed for abuse. 1. The facility failed to ensure LVN H reported a verbal and physical abuse allegation immediately to the Abuse Coordinator when Resident #3 threw coffee and threatened to kill Resident #7. Resident #7 reacted and hit Resident #3 on side of head with her fist on 05/14/2025. 2. The facility failed to ensure LVN K reported a verbal abuse allegation immediately to the Abuse Coordinator when Resident #3 was cussing at her and calling her an evil bitch and Resident #7 responded she would beat her ass on 05/18/2025. 3. The facility failed to report a physical abuse allegation to the State Agency within 2 hours when Resident #3 picked up silverware from the dining table and hit Resident #4 on top of her right hand on 04/19/2025. The physical abuse allegation was not reported to the state agency. 4. The facility failed to report a physical abuse allegation to the State Agency within 2 hours when Resident #3 punched an unidentified resident in the chest on 5/27/2025. 5. The facility failed to report a physical abuse allegation to the State Agency within 2 hours when Resident #3 was verbally and physically aggressive to Resident #5 and hit her in the face on 6/11/2025. 6. The facility failed to report sexual abuse allegation to the State Agency within 2 hours when it was reported that dietary staff witnessed Resident #6 in the secure unit TV room with her hand down Resident #1's pants and Resident #1 was holding Resident #6's hand and arm and would not allow it to be removed. Nursing staff had to manually remove Resident #6's hand from Resident #1's penis and Resident #1 became angry on 03/12/2025. 7. The facility failed to report sexual abuse allegation to the State Agency within 2 hours when on 8/20/2025 at 4:30 p.m. CNA A witnessed Resident #1 was up behind Resident #2 in dining room/nook area and put his hands on her shoulders and waist and started rubbing his privates against her backside (dry-humping - both residents clothed). The sexual abuse allegation was not reported to the State Agency until 8/21/2025 at 11:32 a.m. greater than 2 hours after the incident occurred. 8. The facility failed to report neglect allegation to the State Agency within 24 hours when it was reported on 7/13/2025 at 12:30 a.m. Resident #2 had an unwitnessed fall and sustained multiple injuries. The neglect allegation was not reported to the State Agency until 7/14/2025 at 9:44 a.m. greater than 24 hours after the incident occurred. An Immediate Jeopardy (IJ) was identified on 10/21/2025. The IJ template was provided to the facility on [DATE] at 5:23 pm. While the IJ was removed on 10/23/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failures could place residents at risk of continued abuse, physical harm, mental anguish, and emotional distress due to violations not being reported as required.Findings included: Resident #3Record review of Resident #3's face sheet, dated 10/20/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 9 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some daily life). Record review of Resident #3's quarterly MDS Assessment, dated 06/20/2025, indicated she was able to make herself understood and understood others. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 4 to 6 days within the 7-day look back period. She required moderate to supervision assistance for self-care and was independent with mobility using a manual wheelchair, required supervision to walk. Record review of Resident #3's care plan revision dated 10/23/2024 indicated Resident #3 had behavior/mod issues and had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with agitation and aggression. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #3 had an updated or revised care plan for aggressive behaviors on 04/18/2025, 04/19/2025, 04/20/2025, 05/14/2025, 05/18/2025, 05/27/2025, and 06/11/2025. Resident #7Record review of Resident #7's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included dementia (loss of cognitive functioning), diabetes (a chronic condition that affects the way the body processes blood sugar), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #7's quarterly MDS Assessment, dated 09/04/2025, indicated she was able to make herself understood and understood others. She had a BIMS score of 02 indicating that she was severely impaired cognition. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) daily within the 7-day look back period and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 4 to 6 days (but not daily) within the 7-day look back period. Record review of Resident #7's care plan revision dated 07/08/2024 indicated Resident #7 had impaired cognitive function/dementia or impaired thought processes. Interventions included administering medications as ordered, communicating with resident/family/caregivers regarding resident's capabilities and needs and consulting psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #7 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 05/14/2025 and 05/18/2025. 1. Record review of Resident #7's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #7 had coffee thrown on her by Resident #3. Resident #7 in return struck Resident #3 on the side of her head with her fist. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. No indication that the physical and verbal altercation was reported to the abuse coordinator. Record review of Resident #3's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #3 threw coffee on Resident #7, called her names and threatened to kill her. Resident #7 struck Resident #3 on the side of her head with her fist. The witnesses to the situation said Resident #3 was not provoked. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. No indication that the physical and verbal altercation was reported to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 10 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some abuse coordinator. 2. Record review of Resident #7's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 stating she would beat her ass, LVN K was able to intervene and separate the residents. No indication that the verbal altercation was reported to the abuse coordinator. Record review of Resident #3's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 calling her an evil bitch LVN K was able to intervene and separate the residents. No indication that the verbal altercation was reported to the abuse coordinator. During an observation on 10/20/2025 at 11:00 a.m., Resident #7 was well groomed, and appropriately dressed. Resident #7 was lying in her bed resting. She was easily aroused but did not respond appropriately to interview questions. Resident #7 with no signs of abuse or fear of staff identified. During an interview on 10/20/2025 at 3:40 p.m., CNA A said she did not recall the incident between Resident #3 and Resident #7 back in May 2025. She said she did not recall Resident #7 having any aggressive behavior but if she was provoked, she may have hit someone. She said Resident #7 is usually quiet and stays to herself. CNA A said that resident to resident altercations, aggressive behaviors, falls, injuries, increase pain are reported to the CN immediately. An attempted telephone interview on 10/20/2025 at 5:10 p.m. and 10/21/2025 at 12:27 p.m. with LVN K, was unsuccessful. Resident #4 Record review of Resident #4's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's annual MDS Assessment, dated 05/05/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and moderately impaired cognitively for daily decision making. She had no indications of behaviors of physical or verbal symptoms directed towards others during the 7-day look back period. Record review of Resident #4's care plan revision dated 01/01/2025 indicated Resident #4 had impaired cognitive function/dementia or impaired thought processes. Interventions included communicating, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, providing homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #4 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 04/19/2025. 3. Record review of Resident #4's progress note/health status note dated 04/19/2025 authored by LVN K indicated Resident #4 was sitting in dining room, when Resident #3 became angry and hit Resident #4 on top of the right hand with wrapped silverware. No injury noted RP notified. Record review of Resident#3's progress note/behavior note dated 04/19/2025 authored by LVN K indicated Resident #3 was angry started screaming at 2 other residents CNA F attempted to redirect Resident #3, she remained angry screaming and a few minutes later Resident #3 picked up wrapped silverware from the table and hit Resident #4 on the hand, incident was not witnessed by CNA F due to residents back turned toward CNA A. During an observation of the secure unit on 10/20/2025 at 11:25 a.m., Resident #3 was observed up in wheelchair well-groomed with no foul odor. She was maneuvering herself up and down the halls independently. She did not answer interview questions appropriately. During an observation on 10/20/2025 at 1:25 p.m., Resident #4 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 11 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some observed resting in bed. She was well groomed with no foul odor. She denied abuse by shaking her head no and nodded her head yes when ask is she felt safe at the facility and was pleased with care. During an interview on 10/21/2025 at 2:45 p.m., RN G said she works the night shift on the secure unit. She said Resident #3 did have a history of aggressive behaviors and usually if behavior continued that it could be an indicator of an UTI and she would collect a urinalysis. She said she does not recall witnessing or being involved in incidents with Resident #3 but provided follow up assessments or notes after the incident occurred. She said if she was notified of an abuse allegation, she would make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator. She said if she witnessed a resident being abused that she would intervene and remove the abuser and keep the resident safe, notify the AC and if staff involved send staff member home. During an interview on 10/22/2025 at 8:00 a.m., CNA F said she worked on the secure unit as a CNA and she had provided care for Resident #3, she said the day of the incident between Resident #3 and Resident #4; Resident #3 was screaming at other residents and she had redirected her and later returned her to the dining room to prepare for supper. She went to get a dinner tray and Resident #3 grabbed the wrapped silverware from the table and hit Resident #4 on top of the right hand. She said after the incident Resident #3 was separated from other residents. She said Resident #3 had a history of aggressive behaviors and she usually could be redirected before behaviors escalated. She said Resident #3 usually starts yelling or screaming prior to physical aggression and staff intervene to prevent physical aggression or trigger. She said Resident #4 was moved off the unit so there were no other incidents between her and Resident #3. She said Resident #3 and Resident #5 have a history of altercations because they wheel themselves around the unit and staff try to watch them and make sure that they do not have incident or altercations. 4. Record review of Resident #3's progress note/behavior note dated 05/27/2025 authored by LVN H indicated Resident #3 punched an unidentified resident in her chest. When asked why and what the other resident done to her, she stated, I don't remember, I just have so much anger inside. Resident #5Record review of Resident #5's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #5's quarterly MDS Assessment, dated 06/13/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking and had no indications of behaviors of physical or verbal symptoms directed towards others during the 7-day look back period. Record review of Resident #5's care plan revision dated 07/08/2024 indicated Resident #5 had impaired cognitive function/dementia or impaired thought processes. Interventions included communicating, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, providing homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #5 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 06/11/2025. 5. Record review of Resident #5's incident report of physical aggression received dated 06/11/2025 indicated Resident #5 mistakenly wheeled her wheelchair into Resident #3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 12 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some resulting Resident #3 becoming verbally and physically aggressive and hitting Resident #5 in the face. Residents separated and placed on 1:1 with CNA. RP, MD notified of the incident. No pain or injuries identified at the time of incident. Record review of Resident #3's progress note/incident note dated 06/11/2025 authored by LVN H indicated Resident #3 and Resident #5 were passing in the hallway. Resident #5 gently ran into Resident #3 resulting Resident #3 becoming verbally and physically aggressive and hitting Resident #5 in the face. Residents separated and placed on 1:1 with CNA. No pain or injuries identified at the time of incident. RP, MD and Psych service notified of the incident. MD increased Depakote to 250mg twice a day and asked to assess for continued aggression and sedation. During an observation on 10/21/2025 at 11:00 a.m., Resident #5 was well groomed, and appropriately dressed. Resident #5 was lying in her bed resting. She was easily aroused but did not respond appropriately to interview questions. Resident #5 with no signs of abuse or fear of staff identified. During an interview on 10/21/2025 at 1:34 p.m., LVN H said she worked part time at the facility and was assigned to work in the secure unit. She said she was familiar with Resident #3 and recalled her to have a history of aggressive behaviors and repeated behaviors with Resident #4, #5 and #7. She said if she witnessed any abuse or aggression that she would separate the residents, provide assessment and contact the RP, Psych services and MD/NP. She said she recalled Resident #3 throwing coffee and threatening Resident #7; Resident #7 reacted by hitting Resident #3, she does not recall reporting the incident to the abuse coordinator. Resident #7 She said she does not recall who Resident #3 punched in the chest on 05/25/2025 but if she had to guess it would be Resident #5 or #7 because of the repeated aggression/altercations between the two. She said Resident #4 was moved off the secure unit so the aggressive behaviors between her and Resident #3 stopped. She said she recalled one incident between Resident #3 and Resident #7 screaming at each other in the hall several months ago but does not recall the outcome of the perpetrator. She said she recalls notifying the Psych services and MD/NP several times regarding aggressive behaviors from Resident #3. She said during the 06/11/2025 incident between Resident #3 and #5 she notified Psych services and MD/NP but then she recontacted MD because Psych services were not providing treatment plan for the aggressive behaviors and she discussed this concern with the MD/NP. She said the MD/NP ordered medication increase of Resident #3's Depakote to 250 mg twice a day and that it seemed to help manage and decrease the aggressive behaviors. She said she does not recall receiving orders for the residents she reported to Psych services or MD/NP for aggressive behaviors to be transferred to behavioral hospital during the aggressive behaviors' incidents. She said all abuse allegations were to be reported to the Administrator immediately after the involved residents were safe. Resident #6 Record review of Resident #6's face sheet, dated 10/21/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 was discharged on 09/25/2025. Resident #6 had diagnoses which included dementia (loss of cognitive functioning), and personal history of traumatic brain injury (sudden injury that causes damage to the brain). Record review of Resident #6's admission MDS Assessment, dated 03/04/2025, indicated she had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, behaviors of rejecting care 1 to 3 days and wandering 4 to 6 days (but less than daily) during the 7 days look back period. No behaviors of abusing others sexually or public sexual acts identified. She required assistance for self-care and was independent with transfers and required supervision with ambulation. Record review of Resident #6's care plan with a target date of 09/08/2025 indicated Resident #6 had an impaired cognitive function/dementia or impaired thought process. Interventions included clear communications, to ask yes or no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 13 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #6 had an updated or revised care plan for receiving sexual behavior from another resident on 03/12/2025. Resident #1 Record review of Resident #1's face sheet, dated 10/20/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), dementia (loss of cognitive functioning), and impulse disorder (conditions that involve difficulties in controlling emotions and behaviors, particularly those that are aggressive or antisocial). Record review of Resident #1's quarterly MDS Assessment, dated 09/09/2025, indicated he was severely impaired cognitively with a BIMS score of 6. He had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurring 1 to 3 days during the 7-day look back period. He required supervision assistance for self-care and mobility. Record review of Resident #1's care plan with a revision date of 06/17/2025 indicated Resident #1 had psychosocial wellbeing problems to include disorganized thinking, hallucinations, delusion, verbal aggression, easily annoyed, concentration problems, lack of energy, sleep problems, resist care and wandering related to schizophrenia and insomnia with interventions to include encourage participation from resident who depends on others to make own decision, psych services with continue to monitor patient for changes in mood/behaviors and medication management, and support the resident to set realistic goals. The care plan did not indicate Resident #1 had an updated or revised care plan for sexual behaviors on 03/12/2025, 03/16/2025, 06/30/2025, and 08/20/2025. 6. Record review of Resident #6's progress note/behavior note dated 03/12/2025 indicated DS C alerted LVN K to check on Resident #1 & #6 who was both sitting in dining room,. LVN K observed Resident #6's hand down the front of Resident #1's pants and Resident #1 was holding Resident #6's hand and arm in place when LVN K told Resident #6 to remove her hand from Resident #1's pants, Resident #1 would not let go of Resident #6's arm. LVN K had to manually remove Resident #6's hand which was wrapped around Resident #1's penis. Record review of Resident #1's progress note/behavior note dated 03/12/2025 indicated DS C alerted LVN K to check on Resident #1 & #6 who was both sitting in dining room, LVN K observed Resident #6's hand down the front of Resident #1's pants and Resident #1 was holding Resident #6's hand and arm in place when LVN K told Resident #6 to remove her hand from Resident #1's pants, Resident #1 would not let go of Resident #6's arm. LVN K had to manually remove Resident #6's hand which was wrapped around Resident #1's penis. Resident #1 became angry yelling at the nurse to leave them alone. Unable to interview Resident #6; she no longer resides at the facility. During an interview on 10/21/2025 at 2:45 p.m. with DS C, he said on 3/12/2025 he was in the secure unit and observed Resident #1 and Resident #6 sitting in the common dining area, . Resident #6 had her hand down Resident #1's pants, he immediately notified the CN/LVN K which was nearby, but her back was to Resident #1 and #6 because she was interacting with other residents. He said LVN K intervened and asked Resident #6 to remove her hand from Resident #1's pants. He said Resident #1 got upset and yelled at LVN K, but LVN K removed Resident 6's hand from Resident #1's pants and removed Resident #6 from the situation. He said what he observed was inappropriate touching/sexual abuse and he reported the allegation immediately to the charge nurse/LVN K. An attempted telephone interview on 10/20/2025 at 5:10 p.m. and 10/21/2025 at 12:27 p.m. with LVN K, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 14 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some was unsuccessful. Resident #2 Record review of Resident #2's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), hypertension (condition in which the force of the blood against the artery walls is too high) and diabetes type 2 (a chronic condition that affects the way the body processes blood sugar). Record review of Resident #2's admission MDS Assessment, dated 07/01/2025, indicated she sometimes was able to make self-understood and sometimes understood others. She was not assessed for the brief interview for mental status because she rarely/never understood. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, but no behaviors symptoms identified within the 7-day look back period. She required moderate assistance and supervision assistance for self-care and supervision with mobility. Record review of Resident #2's care plan revision dated 07/30/2025 indicated Resident #2 had impaired cognitive function/dementia or impaired thought processes r/t dementia. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #2 had an updated or revised care plan for receiving sexual behavior from another resident on 08/20/2025. 7. Record review of Resident #1's progress note/behavior note dated 03/16/2025 authored by LVN K indicated CNA notified LVN K that Resident #1 entered his room while she was assisting roommate back to bed and was observed by CNA and roommate masturbating, CNA requested Resident #1 to stop, and he became angry and screamed at the CNA. CNA was able to redirect Resident #1. Record review of Resident #1's progress note/health status note dated 06/30/2025 authored by LVN K indicated another resident came and reported to staff that Resident #1 was in the middle of the common area and had exposed his private area and was holding it. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated NP and RP was notified of Resident #1's sexual behaviors and received a new order to send Resident #1 to behavioral center and start Depo-Provera 150mg/ml and one on one supervision was initiated. Record review of Resident #2's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of the facility's PIR, dated 08/28/2025, incident category as abuse signed by the ADON on 08/28/2025. The PIR indicated the incident occurred on 08/20/2025 at 4:30 p.m., in the dining room of the secure unit. The PIR indicated CNA A witnessed Resident #1 walked up behind Resident #2, put his hands on her shoulders and was rubbing his private area on her backside. Residents were separated immediately, RN D performed a head-to-toe assessment on both residents, no injury. Resident #2 said stated he didn't hurt me. Resident #1 stated I'm sorry. Investigation summary indicated CNA A intervened immediately and told Resident #1 to stop and he immediately walked off. Resident #2 was unable to be interviewed due to advanced Dementia. Resident #1 stated yes, I rubbed her back and I shouldn't have and stopped when CN told me to. Provider actions taken post-investigation was due to eyewitness and Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 15 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete admitting to the situation, the allegation was confirmed. Resident #1 was immediately placed on 1:1 supervision with a new medication prescribed for Depo-Provera and referred to a behavioral hospital. Resident #1 remained on 1:1 monitoring until transferred to behavioral hospital on [DATE]. The sexual abuse allegation was not reported to the State Agency until 8/21/2025 at 11:32 a.m. greater than 2 hours after the incident occurred. During an interview on 10/20/2025 at 3:00 p.m., LVN E interview said she did not routinely work in the secure unit, she was covering a shift, but she was familiar with the residents on the secure unit. She said she is made aware during shift reports of any resident incidents, behaviors, monitoring required and task due. She said she was not aware of any specific residents on the secure unit currently requiring 1:1 monitoring but due to the cognitive impairment of most of the secure unit residents they must be monitored closely. She said the secure unit has a designated nurse, three CNAs and assistance from restorative aide and activity aide routinely during day shift, so plenty of staff for monitoring. She said as a CN if an abuse allegation is reported to her, she responded immediately, separating involved individuals, and completed head to toe assessment, notified RP, MD, DON, Administrator/AC, hospice (if applicable) and followed orders as received. LVN E said she is aware of Resident #1's sexual behaviors but has not witnessed these behaviors during her assigned shifts. She said Resident #3 did have a history of aggressive behaviors with Resident #4 & #5; Resident #4 has been moved off the secure unit so the two no longer have contact. She said Resident #3 and #5 both still reside on the secure unit and staff attempt to prevent any altercations or interactions between the two. She said they are both up in their wheelchairs in the hallways and that is when the incidents occur due to one b Event ID: Facility ID: 676055 If continuation sheet Page 16 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 7 of 10 residents (Resident's #1, #2, #3, #4, #5, #7, and #8) reviewed for care plans. 1. The facility failed to develop, revise and implement interventions in Resident #1's care plan on 03/12/2025, 07/01/2025 and 08/20/2025 to include interventions to prevent sexual abuse of other residents. 2. The facility failed to ensure Resident #3's care plan was updated to indicate Resident #3 had alleged abuse allegations on 04/19/2025, 05/14/2025, 05/18/2025, 05/27/2025 and 06/11/2025. 3. The facility failed to ensure Resident #8's comprehensive care plan was completed to maintain the resident's highest practicable physical well-being for skin integrity, meeting emotional, intellectual, physical, and social needs, ADL self-care, fall risk and diagnosis within 7 days of comprehensive assessment. 4. The facility failed to develop Resident #4's care plan to address residents' safety after Resident #4 was involved in a resident-to-resident incident on 04/19/2025. 5. The facility failed to develop Resident #7's care plan to address residents' safety after Resident #7 was involved in a resident-to-resident incident on 05/14/2025 and 05/18/2025. 6. The facility failed to develop Resident #5's care plan to address residents' safety after Resident #5 was involved in a resident-to-resident incident on 06/11/2025. 7. The facility failed to develop Resident #2's care plan to address residents' safety after Resident #2 was involved in a resident-to-resident incident on 08/20/2025. An Immediate Jeopardy (IJ) was identified on 10/21/2025. The IJ template was provided to the facility on [DATE] at 5:23 pm. While the IJ was removed on 10/23/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of their needs not being identified and services put in place to address their needs. Findings included: 1. Record review of Resident #1's face sheet, dated 10/20/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), dementia (loss of cognitive functioning), and impulse disorder (conditions that involve difficulties in controlling emotions and behaviors, particularly those that are aggressive or antisocial). Record review of Resident #1's quarterly MDS Assessment, dated 09/09/2025, indicated he was severely impaired cognitively with a BIMS score of 6. He had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurring 1 to 3 days during the 7-day look back period. He required supervision assistance for self-care and mobility. Record review of Resident #1's care plan with a revision date of 06/17/2025 indicated Resident #1 had psychosocial wellbeing problems to include disorganized thinking, hallucinations, delusion, verbal aggression, easily annoyed, concentration problems, lack of energy, sleep problems, resist care and wandering related to schizophrenia and insomnia with interventions to include encourage participation from resident who depends on others to make own decision, psych services with continue to monitor patient for changes in mood/behaviors and medication management, and support the resident to set realistic goals. The care plan did not indicate Resident #1 had an updated or revised care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 17 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some for sexual behaviors on 03/12/2025, 03/16/2025, 06/30/2025, and 08/20/2025. Record review of Resident #1's progress note/behavior note dated 03/12/2025 indicated DS C alerted LVN K to check on Resident #1 & #6 who was both sitting in dining room, LVN K observed Resident #6's hand down the front of Resident #1's pants and Resident #1 was holding Resident #6's hand and arm in place when LVN K told Resident #6 to remove her hand from Resident #1's pants, Resident #1 would not let go of Resident #6's arm. LVN K had to manually remove Resident #6's hand which was wrapped around Resident #1's penis. Resident #1 became angry yelling at the nurse to leave them alone. Record review of Resident #1's progress note/behavior note dated 03/16/2025 authored by LVN K indicated CNA notified LVN K that Resident #1 entered his room while she was assisting roommate back to bed and was observed by CNA and roommate masturbating, CNA requested Resident #1 to stop, and he became angry and screamed at the CNA. CNA was able to redirect Resident #1. Record review of Resident #1's progress note/health status note dated 06/30/2025 authored by LVN K indicated another resident came and reported to staff that Resident #1 was in the middle of the common area and had exposed his private area and was holding it. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated NP and RP was notified of Resident #1's sexual behaviors and received a new order to send Resident #1 to behavioral center and start Depo-Provera 150mg/ml and one on one supervision was initiated. 2. Record review of Resident #3's face sheet, dated 10/20/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #3's quarterly MDS Assessment, dated 06/20/2025, indicated she was able to make herself understood and understood others. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 4 to 6 days within the 7-day look back period. She required moderate to supervision assistance for self-care and was independent with mobility using a manual wheelchair, required supervision to walk. Record review of Resident #3's care plan revision dated 10/23/2024 indicated Resident #3 had behavior/mod issues and had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with agitation and aggression. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #3 had an updated or revised care plan for aggressive behaviors on 04/18/2025, 04/19/2025, 04/20/2025, 05/14/2025, 05/18/2025, 05/27/2025, and 06/11/2025. Record review of Resident#3's progress note/behavior note dated 04/18/2025 authored by LVN K indicated Resident #3 attempted to hit another resident who was wheeling themselves down hallway in wheelchair, resident angrily stated that that lady is following me nurse redirected patient and told resident she was not being followed that she was going in the opposite direction of the other resident. Record review of Resident#3's progress note/behavior note dated 04/19/2025 authored by LVN K indicated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 18 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #3 was angry started screaming at 2 other residents CNA F attempted to redirect Resident #3, she remained angry screaming and a few minutes later Resident #3 picked up wrapped silverware from the table and hit Resident #4 on the hand, incident was not witnessed by CNA F due to residents back turned toward CNA A. Record review of Resident #3's progress note/behavior note dated 04/20/2025 authored by LVN K indicated Resident #3 telling other residents that they are trash and that she will call the cops on them staff unable to redirect, resident becomes angry and screams at staff. Record review of Resident #3's progress note/health status note dated 04/22/2025 authored by RN D Resident #3 continues day 3 follow-up status post hitting another resident with a spoon. Resident does not remember hitting anyone. She continues to have episodes of verbal aggression, requiring redirection at times. UA was collected for analysis due to increased aggression. Record review of Resident #3's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #3 threw coffee on Resident #7, called her names and threatened to kill her. Resident #7 struck Resident #3 on the side of her head with her fist. The witnesses to the situation said Resident #3 was not provoked. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. Record review of Resident #3's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 calling her an evil bitch LVN K was able to intervene and separate the residents. Record review of Resident #3's progress note/behavior note dated 05/27/2025 authored by LVN H indicated Resident #3 punched an unidentified resident in her chest. When asked why and what the other resident done to her, she stated, I don't remember, I just have so much anger inside. Record review of Resident #3's progress note/incident note dated 06/11/2025 authored by LVN H indicated Resident #3 and Resident #5 were passing in the hallway. Resident #5 gently ran into Resident #3 resulting Resident #3 becoming verbally and physically aggressive and hitting Resident #5 in the face. Residents separated and placed on 1:1 with CNA. No pain or injuries identified at the time of incident. RP, MD and Psych service notified of the incident. MD increased Depakote to 250mg twice a day and asked to assess for continued aggression and sedation. 3. Record review of Resident #8's face sheet, dated 10/20/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 09/04/2025. Resident #1 had diagnoses which included muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), pressure ulcer, diabetes type 1 (chronic condition in which the pancreas produces little or no insulin) cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #8's admission MDS Assessment, dated 08/20/2025, indicated he was usually able to make herself understood and sometimes understood others. He had a BIMS score of 00 indicating that he was severely impaired cognitively. He had wandering episodes 1 to 3 days of the 7-day look back period. He required moderate assistance for self-care and moderate assistance with transfers/mobility and maximum assistance with tub/shower transfer and ambulation. He uses a standard wheelchair for mobility. Record reviews of Resident #8's baseline care plan with admission date of 08/07/2025 and completion date of 08/09/2025 to include initial goals, dietary orders, therapy services, safety, ADLs, special treatment, bowel/bladder and skin concerns. No comprehensive care plan was developed prior to Resident #8's discharge on [DATE]. 4. Record review of Resident #4's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Alzheimer's Disease (progressive disease that destroys (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 19 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's annual MDS Assessment, dated 05/05/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and moderately impaired cognitively for daily decision making. She had no indications of behaviors of physical or verbal symptoms directed towards others during the 7-day look back period. Record review of Resident #4's care plan revision dated 01/01/2025 indicated Resident #4 had impaired cognitive function/dementia or impaired thought processes. Interventions included communicating, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, providing homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #4 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 04/19/2025. Record review of Resident #4's progress note/health status note dated 04/19/2025 authored by LVN K indicated Resident #4 was sitting in dining room, when Resident #3 became angry and hit Resident #4 on top of the right hand with wrapped silverware. No injury noted RP notified. 5. Record review of Resident #7's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included dementia (loss of cognitive functioning), diabetes (a chronic condition that affects the way the body processes blood sugar), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #7's quarterly MDS Assessment, dated 09/04/2025, indicated she was able to make herself understood and understood others. She had a BIMS score of 02 indicating that she was severely impaired cognition. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) daily within the 7-day look back period and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 4 to 6 days (but not daily) within the 7-day look back period. Record review of Resident #7's care plan revision dated 07/08/2024 indicated Resident #7 had impaired cognitive function/dementia or impaired thought processes. Interventions included administering medications as ordered, communicating with resident/family/caregivers regarding resident's capabilities and needs and consulting psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #7 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 05/14/2025 and 05/18/2025. Record review of Resident #7's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #7 had coffee thrown on her by Resident #3. Resident #7 in return struck Resident #3 on the side of her head with her fist. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. Record review of Resident #7's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 stating she would beat her ass, LVN K was able to intervene and separate the residents. 6. Record review of Resident #5's face sheet, dated 10/20/2025, indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 20 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #5's quarterly MDS Assessment, dated 06/13/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking and had no indications of behaviors of physical or verbal symptoms directed towards others during the 7-day look back period. Record review of Resident #5's care plan revision dated 07/08/2024 indicated Resident #5 had impaired cognitive function/dementia or impaired thought processes. Interventions included communicating, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, providing homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #5 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 06/11/2025. Record review of Resident #5's incident report of physical aggression received dated 06/11/2025 indicated Resident #5 mistakenly wheeled her wheelchair into Resident #3 resulting Resident #3 becoming verbally and physically aggressive and hitting Resident #5 in the face. Residents separated and placed on 1:1 with CNA. RP, MD notified of the incident. No pain or injuries identified at the time of incident. 7. Record review of Resident #2's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), hypertension (condition in which the force of the blood against the artery walls is too high) and diabetes type 2 (a chronic condition that affects the way the body processes blood sugar). Record review of Resident #2's admission MDS Assessment, dated 07/01/2025, indicated she sometimes was able to make self-understood and sometimes understood others. She was not assessed for the brief interview for mental status because she rarely/never understood. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, but no behaviors symptoms identified within the 7-day look back period. She required moderate assistance and supervision assistance for self-care and supervision with mobility. Record review of Resident #2's care plan revision dated 07/30/2025 indicated Resident #2 had impaired cognitive function/dementia or impaired thought processes r/t dementia. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #2 had an updated or revised care plan for receiving sexual behavior from another resident on 08/20/2025. Record review of Resident #2's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of the facility's PIR, dated 08/28/2025, incident category as abuse signed by the ADON on 08/28/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 21 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some The PIR indicated the incident occurred on 08/20/2025 at 4:30 p.m., in the dining room of the secure unit. The PIR indicated CNA A witnessed Resident #1 walked up behind Resident #2, put his hands on her shoulders and was rubbing his private area on her backside. Residents were separated immediately, RN D performed a head-to-toe assessment on both residents, no injury. Resident #2 said stated he didn't hurt me. Resident #1 stated I'm sorry. Investigation summary indicated CNA A intervened immediately and told Resident #1 to stop and he immediately walked off. Resident #2 was unable to be interviewed due to advanced Dementia. Resident #1 stated yes, I rubbed her back and I shouldn't have and stopped when CN told me to. Provider actions taken post-investigation was due to eyewitness and Resident #1 admitting to the situation, the allegation was confirmed. Resident #1 was immediately placed on 1:1 supervision with a new medication prescribed for Depo-Provera and referred to a behavioral hospital. Resident #1 remained on 1:1 monitoring until transferred to behavioral hospital on [DATE]. The sexual abuse allegation was not reported to the State Agency until 8/21/2025 at 11:32 a.m. greater than 2 hours after the incident occurred. During an interview on 10/21/2025 at 3:50 p.m., the ADON/MDS Coordinator said she was responsible for updating resident care plans and she had fallen behind due to her workload. She said the residents that were involved in resident-to-resident altercations should have been discussed during a morning meeting and care plan updated to reflect the resident individualized care and interventions to keep all residents safe. She said if care plans are not updated/revised it does not reflect the current resident's need and care which could result in inappropriate care, accidents or injuries. During an interview on 10/21/2025 at 4:00 p.m., the DON said the ADON/MDS Coordinator was responsible for updating resident care plans. The DON said she and ADON were having to cover floor charge nurse shifts and that some responsibility had fallen behind. She said during IDT care plan meetings and morning stand up meetings, any changes in residents identified that require a care plan revision should have been done then and not delayed. She said residents care plans should be individualized and reflect the residents' needed care and interventions to keep all residents safe. She said if care plans are not updated/revised it does not reflect the current resident's need and care which could result in inappropriate care, accidents or injuries. During an interview on 10/21/2025 at 4:15 p.m., the Administrator said all incidents and allegations are discussed during morning meetings and if care plans need to be updated that the ADON/MDS Contractor was responsible for care plans and interventions updates. He is unsure why the care plans were not updated and if the care plans were not updated or revised, the care plan would not reflect the current resident's needs. He stated new interventions should be added to the care plan regarding recurrent resident-to-resident altercations. He said the DON should have been assigned the responsibilities of ensuring the care plan was updated. He said not revising care plans could result in inappropriate care, accidents or injuries. Record review of a facility policy revised March 2022, titled, Care Plans, Comprehensive Person-Centered Policy indicated, 2. The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment, and no more than 21 days after admission. 12. The interdisciplinary team reviews and updates the care plans; a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met. An Immediate Jeopardy (IJ) was identified on 10/21/2025. The IJ template was provided to the facility on [DATE] at 5:23 pm. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for Immediate Jeopardy for F656 was accepted on 10/22/2025 at 7:05 p.m. and reflected the following: Care plans for residents 1 & 3 have been updated to include interventions to prevent abuse and manage behaviors on 10/21/25 by ADON/MDS nurse. ADON/MDS nurses have been in-serviced on when care plans are due and the importance of completing them in a timely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 22 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some manner by the Administrator. Administrator and DON will also monitor daily notifications from medical charting software for upcoming care plans due dates. Resident #8 had a baseline care plan completed within 48 hours of admission but discharged on day 14 before another care plan was completed. MDS coordinator will submit weekly to DON and Administrator care plan list to indicate which care plans are due. DON has reviewed all care plans due dates and none are overdue as of 10/22/25. On 10/22/25 All residents had care plans reviewed by DON and after adjustments were made all care plans are now found to be accurate. All residents on secure unit were assessed by DON for injury and signs/symptoms of abuse and neglect on 10/22/25. Care plan updates will be emailed by the ADON/MDS nurse to each nurses' station when a change occurs or a new focus is added such as but not limited to a change in behavior. The administrator will monitor for compliance by being copied on emails to nurse's stations. All charge nurses have been notified of this new system by DON. 6 out of 8 nurses have been in-serviced by DON by cell phone on facility's policy and procedure for care plans and interventions. 46 out of 51 staff were contacted and in-serviced by DON on 10/22/25 on abuse, neglect and exploitation, reporting suspected abuse, and intervention methods to include redirection. No staff will be allowed to work until this in-service is completed. Monitoring of the Plan of Removal included the following: Record review indicated Residents #1's care plan was updated on 10/21/2025 to include he was at risk for initiating inappropriate sexual behaviors and interventions of monitoring, administering Depo-Provera as prescribed, assist the resident to develop more appropriate methods of coping and interacting such as visiting with other male residents, staff to intervene to protect the rights and safety of others, offer activities, recognize changes in condition and report, notify CN immediately of any inappropriate behaviors and remove resident from area for any signs of inappropriateness such as masturbating in public, exposing self in front of others, do not scold resident. Record reviews of Resident #3's care plan indicated it was updated with resident has potential to be verbally aggressive yelling and cursing at staff/residents related to dementia and poor impulse control on 10/21/2025. Interventions include when resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. Record reviews of Resident #2, #4, #5, and #7 care plans indicated they were updated with safety and goals that residents will remain safe on 10/22/2025. Interventions included encourage use of prescribed safety assistive devices, perform safety risk evaluation on admission and as needed upon change in condition and safety measures including strategies to reduce risk of infection, falls, injuries, incidents and initiate as appropriate. Record reviews of Resident #8's baseline care plan with admission date of 08/07/2025 and completion date of 08/09/2025 to include initial goals, dietary orders, therapy services, safety, ADLs, special treatment, bowel/bladder and skin concerns. No comprehensive care plan developed prior to Resident #8's discharge on [DATE]. Record review of the facility audit completed by the DON she reviewed all care plans due dates, and none are overdue as of 10/22/25. DON reviewed all residents' care plans after adjustments were made, and care plans are accurate on 10/22/2025. Record review of an emails from MDS Coordinator on 10/22/2025 to charge nurses, DON and the Administrator indicating detailed revisions to Resident #1, #2, #3, #4, #5, #7. Record review of in-service dated 10/22/2025 instructed by the DON and MDS Coordinator indicated 6 out of 8 nursing staff were trained on facility policy and procedure for care plans and interventions. Nursing staff will be notified of care plan changes and updates through charge nurse facility emails. Identified Resident #1's care plan updated with inappropriate behaviors with monitoring interventions added, Resident #3 with verbal and physical aggression with new interventions and Resident #2, #4, #5, and #7 with safety care plan and intervention. During an interview on 10/22/2025 at 10:15 a.m. LVN L said she received training regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676055 If continuation sheet Page 23 of 24 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 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete care plan revision or updates and that the MDS Coordinator or DON would be emailing/notifying the nursing staff of any changes in resident care plans and that CN should be contacting them for any care plans that need to be updated with changes in the resident's condition and to personalize the care plans to meet the resident's needs. LVN L said she was made aware verbally and electronically (email) of Resident #1 and Resident #3 had updates to their care plans which included the monitoring of Resident #1 and watching Resident #3 was agitated and to intervene before agitation escalates. During an interview on 10/22/2025 at 2:30 p.m., LVN E said she was verbally and electronically notified of updated care plans on Resident #1, #3, #2, #4, #5, and #7. She said Resident #1's care plan had changed, and he is being monitored q 15 minutes to identify any changes in his behaviors and Resident #3's care plan was updated to intervene immediately if agitation identified and the other care plan updates were to ensure residents safety. During interviews conducted on 10/22/2025 at 9:10 a.m. through 10/23/2025 at 10:00 a.m. included LVN E, LVN H, LVN K, LVN L, LVN V, LVN BB, RN MM, and LVN NN. All staff interviewed were able to identify care plans are person centered measures to maintain the resident's highest practicable physical well-being for skin integrity, meeting emotional, intellectual, physical, and social needs, ADL self-care, fall risk and diagnosis MDS. All staff interviewed said resident's care plan should be reviewed and updated when residents have a change in condition, like falls with injuries, unmanaged or repetitive aggressive behaviors. All staff interviewed said the MDS or DON would be notifying charge nurses via email or in person of any care plan updates and/or revision and if charge nurse identifies care plans that need to be revised or updated, they are to notify Event ID: Facility ID: 676055 If continuation sheet Page 24 of 24