Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shady Acres Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide RN coverage for 8 consecutive hours daily and failed to maintain a full-time RN DON. Payroll review showed multiple days with no RN services, and interviews confirmed gaps in DON coverage after successive resignations. The HR Director, ADON, and Administrator all acknowledged periods when neither an RN nor a DON was present, while the facility continued interviewing for the DON role.
Kitchen sanitation and staff hygiene deficiencies were observed when the Dietary Supervisor and a Dietary Aide/Cook worked without beard restraints, a bug-filled fly tape was hanging near refrigerator B, the kitchen floors were sticky with debris, refrigerator A had fuzzy green spots on a wire rack, and the ice machine had lime buildup inside and out. Interviews showed staff knew beard restraints were required and that the ice machine had not been cleaned on a known schedule.
A resident with HTN and severe cognitive impairment was ordered two BP medications with hold parameters, but an LVN administered both meds on multiple occasions when the resident’s BP was outside the prescribed limits. The LVN said it was a careless mistake and acknowledged the meds should have been held as ordered; the ADON and Administrator stated meds were expected to be given according to physician orders.
Loose Unidentified Pills Found in Medication Cart Drawers: The Hall D and Hall C med carts were observed in use while the QA nurse was giving meds from them, and each cart had loose unidentified pills in the 2nd drawer. Hall D contained 18 whole and 5 broken pills, and Hall C contained 5 whole and 1 broken pill. The QA nurse, ADON, and Administrator stated the loose meds had been overlooked, and the facility policy required drugs and biologicals to be stored in a safe, secure, orderly manner in their original packaging.
Failure to use PPE during ADL care for a resident on EBP. A resident with dysphagia, severe cognitive impairment, and a feeding tube was observed receiving peri-care and brief care without a gown, even though EBP signage and PPE were present at the room entrance. Two CNAs acknowledged they knew the resident was on EBP but forgot to don a gown, and both staff members’ uniform clothes touched the resident’s gown and bed linens during care.
Two residents were not protected from sexual abuse when a male resident, with no prior documented history of sexual behaviors, inappropriately touched one female resident's breast and genital area and touched another female resident's breast without consent. Both female residents had cognitive impairments and reported the incidents to staff, with no physical injuries found. The incidents were categorized as abuse, and the male resident later admitted to inappropriate behaviors during a behavioral hospital stay.
The facility did not submit investigation results for three separate incidents of alleged abuse and injury of unknown origin to the State Survey Agency within the required 5-day period. Although investigations were completed and documented in the electronic medical record, the responsible staff member failed to manually upload the reports to the state system, resulting in delayed reporting for incidents involving two residents with allegations of inappropriate touching and one resident with an unexplained injury.
Multiple residents with severe cognitive impairments and behavioral health diagnoses were involved in repeated incidents of sexual, physical, and verbal abuse, including inappropriate sexual contact, physical aggression, and threats. Staff intervened in some cases but did not consistently update care plans, report incidents to the abuse coordinator, or ensure adequate supervision, resulting in a pattern of unaddressed abuse and neglect.
Multiple incidents of physical, verbal, and sexual aggression between residents, as well as an incident of neglect, were not reported by staff to the abuse coordinator or State Agency within required timeframes. Staff failed to follow established procedures for immediate and timely reporting after witnessing or being informed of abuse or neglect, despite residents' significant cognitive impairments and behavioral histories. Care plans were not updated to reflect new or ongoing aggressive or sexual behaviors following these events.
The facility did not consistently update or revise care plans for several residents following incidents of aggression, abuse, or significant behavioral changes. For example, a resident with severe cognitive impairment and behavioral issues repeatedly engaged in inappropriate sexual and aggressive behaviors without timely care plan updates, while other residents who experienced or exhibited aggression did not have their care plans revised to address safety or new interventions. Staff interviews confirmed that care plan updates were delayed due to workload and staffing issues, and required policy timelines for care plan development and revision were not met.
The facility failed to maintain clean oxygen concentrator filters for three residents requiring respiratory care. A resident with COPD, another with lung cancer and congestive heart failure, and a third with acute respiratory failure were all found with concentrators covered in dust and lacking proper filter maintenance. Staff interviews revealed confusion over responsibility for cleaning, leading to oversight and potential risk of decreased airflow.
A gas stove burner in the facility's kitchen failed to light, as observed during a survey. The Dietary Manager and Maintenance Director were responsible for ensuring equipment functionality, with staff trained to report malfunctions. The Maintenance Director identified a potential grease clog in the pilot nozzle and ordered a replacement part. The Administrator confirmed that all burners were operational during his last inspection.
A facility failed to accurately assess a resident's medical needs, resulting in incorrect MDS coding for insulin use. The resident, who had no diabetes diagnosis or insulin orders, was mistakenly recorded as receiving insulin injections. Staff interviews confirmed the error, which was acknowledged by the ADON responsible for the MDS. The DON noted that such inaccuracies could lead to inappropriate care.
A facility failed to maintain an effective infection control program, as a resident's pleural drain bag was found on the floor, contrary to care plan directives. The resident, with lung cancer and memory issues, was dependent on ADLs. Staff interviews confirmed the drain bag should not be on the floor to prevent infection, but the facility lacked a formal policy for handling pleural drain bags.
A resident at high risk for falls, with Alzheimer's and Parkinson's, experienced an unwitnessed fall resulting in a laceration above her eye due to the absence of a fall mat. The care plan did not include a fall mat as an intervention, and staff oversight led to the mat not being placed by the bed. Facility policies on safety and fall risk management were not followed.
A resident with dementia and schizophrenia was verbally abused by a CNA, who made intimidating remarks while attempting to get the resident out of bed. The Administrator overheard the incident and confirmed the CNA's inappropriate behavior. Despite prior training on abuse prevention, the CNA admitted to raising her voice due to personal stress. The resident required supervision and assistance with ADLs and had behavioral issues, which may have contributed to the situation.
A resident with Alzheimer's and a history of falls experienced a witnessed fall in the lounge area, resulting in a right hip fracture. The facility reported the incident as neglect to TULIP but did not conduct a thorough investigation or submit a 5-day report, believing the incident was not reportable. The QA LVN and Administrator attempted to delete the report but did not confirm its removal, failing to adhere to the facility's policy on reporting and investigation.
A resident with Alzheimer's, dementia, and Parkinson's was at high risk for falls, but the facility failed to include a fall mat in her care plan. This oversight led to two incidents where the resident sustained injuries from falls. Staff interviews confirmed the care plan should have included a fall mat, and the facility's policies emphasized the need for specific interventions to reduce accident risks.
A facility failed to provide adequate supervision and safety measures for residents who smoke, resulting in a serious incident where a resident on oxygen therapy sustained burns after her oxygen caught fire. The incident involved two other residents who were smoking in a non-designated area without supervision. Staff were unaware of residents' smoking statuses and failed to enforce policies regarding smoking materials, contributing to the unsafe conditions.
A resident using oxygen sustained burns after smoking in a non-designated area with two other residents. The facility failed to supervise the residents, allowed smoking materials in rooms, and did not reassess smoking safety. Staff were unaware of smoking policies, contributing to the incident.
The facility failed to implement comprehensive care plans for three residents regarding smoking safety. One resident with severe cognitive impairment was observed smoking while on oxygen without a care plan addressing smoking safety. Another resident, cognitively intact, did not comply with the smoking policy and kept smoking supplies in his room, while a third resident's care plan was not updated after being found with cigarettes. Staff were unaware of residents' smoking habits and supervision needs, increasing the risk of unsafe smoking practices.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to utilize the services of an RN for 8 consecutive hours a day, 7 days a week, and failed to designate an RN as the DON on a full-time basis. Review of RN payroll hours for 01/01/26 through 04/29/26 showed no RN services on 20 dates in January, February, March, and April 2026. The facility also had periods without a DON after the prior DON resigned on 02/18/26, with the HR Director stating there were 6 days in February without a DON, 16 days in March without a DON after another DON resigned on 03/04/26, and 8 days in April without a DON after the next DON resigned on 04/20/26. During interview, the HR Director stated the facility had not hired a full-time DON after the resignations and that the Administrator was responsible for ensuring daily RN coverage and hiring a DON. The HR Director said the facility had been interviewing candidates but had not hired anyone. The ADON, who is an LVN, stated that at times there was neither an RN nor a DON present and that she would seek guidance from a DON at another facility, physicians, Nurse Practitioner, pharmacy, or dietitian when needed. She also stated that having an RN and DON was important because they provided oversight, guidance, and more in-depth assessment when needed. The Administrator acknowledged that the facility did not have RN coverage or an acting DON and stated he expected the facility to have an RN working eight consecutive hours every day and to have an acting or full-time DON. He said the previous DON resigned without notice, the facility had been advertising for the DON position, and there was no corporate RN or regional RN to assist until one was hired. Record review of incidents and accidents for January through April 2026 did not reveal any negative outcomes related to the lack of RN services or DON coverage. The facility policy stated the Nursing Services department is under the direct supervision of an RN and that the DON is a registered nurse employed full-time 40 hours per week.
Kitchen sanitation and staff hygiene deficiencies
Penalty
Summary
Food service safety deficiencies were identified in the kitchen during observation, interview, and record review. The Dietary Supervisor and Dietary Aide/Cook C were observed without beard restraints while working in the kitchen, even though both acknowledged they should have worn them to prevent hair from getting into residents’ food. The Administrator also stated that all staff with beards of any length should wear beard restraints. The kitchen environment was observed to be unsanitary in several areas. A long brown fly tape hanging from the ceiling was located approximately 12 inches from refrigerator B and was filled with bugs. The floors in the kitchen had debris and were sticky throughout. Inside refrigerator A, small fuzzy green spots were observed on the wire rack. There was also lime buildup on the outside and inside of the ice machine. During interviews, the Dietary Supervisor said the floors were mopped daily multiple times a day but the sticky substance could not be removed unless boiling hot water was used. He also said he did not know when the ice machine was last drained and cleaned and did not have a person designated to clean it. The Dietary Aide/Cook C said he was responsible for daily cleaning of the kitchen, including the refrigerator and ice machine, after meal services, but did not know when the ice machine was last drained and cleaned and said it had been a while. The Administrator stated the bug tape should not have been in the kitchen and that the Dietary Supervisor was responsible for overseeing daily and after-meal cleaning of the kitchen and ice machine.
Failure to Hold Blood Pressure Medications per Ordered Parameters
Penalty
Summary
Resident #3, a cognitively severely impaired male with a diagnosis of hypertension, was ordered Lisinopril 10 mg daily to be held if systolic blood pressure was less than 110 or diastolic blood pressure was less than 60, and Metoprolol tartrate 25 mg twice daily to be held if systolic blood pressure was less than 100, diastolic blood pressure was less than 60, or heart rate was less than 60. Review of the April 2026 MAR showed that LVN A administered both blood pressure medications on multiple occasions when the resident’s vital signs were outside the ordered parameters. The medications were given on several dates when the recorded blood pressure did not meet the physician’s hold instructions, including readings of 100/56, 115/57, 103/53, 108/52, and 107/52. During interview, LVN A stated it was a careless mistake and acknowledged the medications should have been held as ordered. The ADON and Administrator stated their expectations were that medications be administered according to physician orders, including parameters. The facility policy stated medications are to be administered in accordance with prescriber orders, including required time frames.
Loose Unidentified Pills Found in Medication Cart Drawers
Penalty
Summary
The facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 2 of 3 medication carts observed, specifically the Hall D and Hall C medication carts. During an observation and interview on 04/28/2026 at 2:25 p.m., the QA nurse stated she was giving patient medication from the Hall D medication cart that day, and the 2nd drawer contained 18 whole and 5 broken loose unidentified pills. She said the medication cart should be cleaned and no loose pills should be in the drawers. During an observation and interview later that day at 2:39 p.m., the Hall C medication cart was also reviewed with the QA nurse, who said she was giving patient medication from that cart that day. The 2nd drawer contained 5 whole and 1 broken loose unidentified pill. The QA nurse, ADON, and Administrator each stated that the nurses giving medication from the carts were responsible for keeping them free of loose pills, and that the loose medication had been overlooked. A facility policy revised April 2019 stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner, in the packaging or dispensing systems in which they are received, and that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Use PPE During ADL Care for Resident on EBP
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 1 of 5 residents reviewed for infection control. Resident #5 was a [AGE]-year-old male admitted with dysphagia, had a BIMS score of 03 on the quarterly MDS indicating severe cognitive impairment, and had a feeding tube included in his nutritional approaches. His care plan stated that he required tube feeding and was dependent with tube feeding and water flushes, and his April 2026 physician orders indicated a tube feeding only diet. During an observation, Resident #5 had Enhanced Barrier Precaution signage in place and PPE was available at the room entrance, but CNA E entered the room to provide ADL care without donning a gown. While CNA E cleaned the resident’s peri-area and changed his brief, CNA F entered and assisted with pulling the resident up in bed. During this care, both CNAs’ bare uniform clothes touched the resident’s gown and bed linens. In interviews, both CNAs stated they knew the resident was on Enhanced Barrier Precaution but forgot to put on a gown. The ADON stated that a resident with a gastrostomy tube was on Enhanced Barrier Precaution and staff should wear a gown and gloves while providing care, and the Administrator stated staff had been trained and retrained on EBP and that the failures violated infection prevention and control requirements.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that two residents were free from sexual abuse, resulting in a deficiency related to resident rights and protection from abuse. One male resident, who was cognitively intact and had diagnoses including mood disorder, dementia, and anxiety disorder, entered the room of a female resident and inappropriately touched her breast and genital area. The female resident, who was moderately cognitively impaired with diagnoses including spina bifida, anxiety disorder, and diabetes, reported the incident to staff. The incident was not witnessed, and the resident stated she told the staff the next day. The male resident denied the allegations at the time, and there was no prior documented history of sexual behaviors for him in the facility before this incident. A second female resident, who had a history of stroke, aphasia, anxiety disorder, and diabetes, reported to staff that the same male resident had touched her breast without consent on an unidentified date. This resident was also moderately cognitively impaired and had difficulty communicating due to her medical condition. The incident was reported after the resident became withdrawn and stopped participating in activities, which was noticed by the activity director. Upon questioning, the resident indicated she had been touched inappropriately. The male resident was already under increased monitoring at the time this second allegation was reported. Both incidents were categorized as abuse, and assessments conducted by nursing staff found no physical injuries to either female resident. The facility's records indicate that staff were able to identify abuse reporting procedures and immediate intervention steps, but the deficiency occurred due to the failure to prevent the male resident from accessing and inappropriately touching the female residents. The male resident later admitted to inappropriate behaviors during a behavioral hospital stay, but continued to deny the allegations to facility staff. There was no documentation of prior sexual behavior history for the male resident before these incidents.
Failure to Timely Report Investigation Results of Abuse and Injury Allegations
Penalty
Summary
The facility failed to report the results of all investigations of alleged abuse, neglect, or injury of unknown origin to the administrator or designated representative and to the State Survey Agency within 5 working days, as required by regulation and facility policy. Specifically, for three separate incidents involving allegations of inappropriate touching and an injury of unknown origin, the Provider Investigation Reports (Form 3613-A) were completed in the facility's electronic medical record system but were not submitted to the Texas Unified Licensure Information Portal (TULIP) within the required timeframe. The Assistant Director of Nursing (ADON), who was responsible for submitting these reports, believed the electronic system would automatically upload the reports, but later realized manual submission was necessary. The first two incidents involved a male resident with diagnoses including mood disorder, dementia, and high risk of heterosexual behaviors, who was alleged to have inappropriately touched two female residents. Both female residents had significant cognitive or physical impairments, including spina bifida, anxiety disorder, depressive episodes, diabetes, stroke, and aphasia. Immediate actions were taken by administration and clinical staff, and thorough investigations were completed, but the results were not timely reported to the State Survey Agency as required. The third incident involved a female resident with Alzheimer's disease, Parkinson's disease, and severe cognitive impairment, who sustained an injury of unknown origin resulting in a hip fracture and other medical complications. Although the investigation was completed and documented, the results were not uploaded to the TULIP system within the mandated 5-day period. Interviews with the ADON and Administrator confirmed the oversight and misunderstanding regarding the submission process, which led to the deficiency.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse and neglect, as evidenced by several incidents involving both sexual and physical abuse among residents. In one instance, a female resident with severe cognitive impairment and a history of traumatic brain injury was observed with her hand down the pants of a male resident, who was also severely cognitively impaired and diagnosed with schizophrenia and impulse disorder. The male resident held the female resident's hand in place and resisted staff intervention, requiring nursing staff to manually remove her hand. The care plans for both residents did not reflect updates or interventions addressing these sexual behaviors, despite prior incidents of inappropriate sexual conduct by the male resident, including exposing himself and masturbating in common areas, as well as inappropriate physical contact with another female resident who was also severely cognitively impaired and unable to communicate effectively. Additional incidents involved physical and verbal aggression between residents. One resident, with Alzheimer's disease and major depressive disorder, exhibited repeated aggressive behaviors, including hitting another resident on the hand with silverware, throwing coffee, making verbal threats, and physically striking other residents. These behaviors were documented in progress notes, but care plans were not updated to address the ongoing aggression or to provide interventions for the victims. In several cases, staff intervened to separate residents and de-escalate situations, but there was no evidence that these incidents were consistently reported to the abuse coordinator or that care plans were revised to reflect the risks and necessary supervision. The report also details failures in communication and documentation, such as not reporting certain abuse allegations to the state agency in a timely manner and lacking evidence of consent or capacity to consent in cases of alleged consensual sexual contact between cognitively impaired residents. Interviews with staff and family members confirmed awareness of behavioral issues and incidents, but also revealed gaps in monitoring, reporting, and care planning. The cumulative effect of these actions and inactions resulted in an Immediate Jeopardy finding, as the facility did not ensure residents' right to be free from abuse and neglect, and failed to implement adequate supervision, assessment, and care plan updates in response to repeated incidents.
Failure to Timely Report Alleged Abuse, Neglect, and Sexual Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or theft were reported immediately to the abuse coordinator and, when required, to the State Agency within the mandated timeframes. Multiple incidents involving resident-to-resident physical and sexual aggression, as well as verbal abuse, were not reported as required. In several cases, staff did not notify the abuse coordinator immediately after witnessing or being informed of abuse allegations, and several incidents were not reported to the State Agency within the required two-hour window for abuse or bodily injury, or within 24 hours for neglect. These failures were identified for seven out of ten residents reviewed for abuse. Specific events included a resident throwing coffee and threatening another, resulting in a physical altercation; a resident verbally abusing another, with threats of physical harm; and multiple instances of physical aggression, such as a resident hitting another with silverware and punching another resident in the chest. There were also incidents of sexual abuse, including a resident placing a hand down another resident's pants and a resident rubbing his private area against another resident. In each of these cases, documentation showed that the incidents were either not reported to the abuse coordinator or not reported to the State Agency within the required timeframe. Additionally, an incident of neglect involving a resident's unwitnessed fall with injuries was not reported to the State Agency within 24 hours. The residents involved had significant cognitive impairments, including diagnoses of Alzheimer's disease, dementia, major depressive disorder, and schizophrenia. Many required supervision or assistance for daily activities and had documented histories of behavioral symptoms such as aggression, inattention, and disorganized thinking. Despite these known risks, the facility did not update care plans to reflect new or ongoing aggressive or sexual behaviors following these incidents, nor did staff consistently follow established procedures for reporting abuse, neglect, or theft as required by regulation.
Failure to Update and Implement Comprehensive Care Plans Following Resident Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. Specifically, care plans were not updated or revised to address significant changes in residents' conditions, including incidents of sexual and physical aggression, as well as abuse allegations. For example, one resident with schizophrenia, dementia, and impulse disorder exhibited repeated sexually inappropriate behaviors and aggression toward others, but the care plan was not updated to include interventions to prevent further incidents on several occasions. Another resident with Alzheimer's disease and major depressive disorder had multiple episodes of verbal and physical aggression toward other residents, including hitting and threatening, yet the care plan was not revised to reflect these behaviors or to implement new interventions after each incident. Several other residents who were victims of resident-to-resident aggression or abuse did not have their care plans updated to address their safety or to reflect the incidents they experienced. In one case, a resident was physically assaulted by another resident, but the care plan was not revised to include safety interventions. Another resident was subjected to inappropriate sexual behavior by a peer, but the care plan did not reflect this event or include measures to protect the resident. Additionally, a resident with significant cognitive impairment and multiple medical diagnoses was discharged before a comprehensive care plan was developed, despite the presence of a baseline care plan. Interviews with facility staff, including the ADON/MDS Coordinator, DON, and Administrator, revealed that care plan updates were delayed due to workload issues and staff covering multiple roles. Staff acknowledged that care plans should be individualized and revised promptly following incidents or changes in condition, but this was not consistently done. Facility policy required care plans to be developed within seven days of the MDS assessment and updated after significant changes, but these requirements were not met for several residents involved in incidents of aggression, abuse, or significant behavioral changes.
Removal Plan
- Care plans for residents 1 & 3 have been updated to include interventions to prevent abuse and manage behaviors 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 manner by the Administrator.
- Administrator and DON will also monitor daily notifications from medical charting software for upcoming care plans due dates.
- 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.
- 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.
- 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.
- Nurses have been in-serviced by DON by cell phone on facility's policy and procedure for care plans and interventions.
- Staff were contacted and in-serviced by DON 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.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents who required oxygen management. Resident #1, a male with chronic obstructive pulmonary disease (COPD), was observed with an oxygen concentrator that lacked necessary air filters, and the areas meant to hold these filters were covered with a thick, dusty substance. This was despite his care plan indicating the need for oxygen at 2 liters per minute by nasal cannula when oxygen saturation fell below 92%. Resident #6, a female with lung cancer and congestive heart failure, was receiving oxygen at 4 liters per minute via nasal cannula. However, the filter on her oxygen concentrator was covered with a thick whitish substance. Interviews revealed confusion among staff about who was responsible for cleaning the filters, with the Maintenance Director believing it was the responsibility of the rental companies, and the ADON stating it should be done weekly by the night shift. Resident #39, a female with acute respiratory failure and heart failure, was also found with an oxygen concentrator filter covered in a thick, dusty substance. Despite her care plan requiring oxygen at 2 liters per minute as needed, the filters were not cleaned or replaced. Interviews with staff, including the DON and the Administrator, indicated that the responsibility for ensuring clean filters was not clearly assigned, leading to oversight and potential risk of decreased airflow to the concentrators.
Gas Stove Burner Malfunction in Kitchen
Penalty
Summary
The facility failed to maintain the gas stove in the kitchen in a safe operating condition, as observed on February 10, 2025, when one of the six burners did not light upon being turned on. The Dietary Manager (DM) noted that the burner had been functioning until that point and speculated that a pot might have splashed over, extinguishing the pilot light. The DM acknowledged responsibility for ensuring all kitchen equipment was operational and stated that staff were trained to report any equipment malfunctions to him or the Maintenance Director. The risk identified was that gas could escape if a knob was accidentally turned and the pilot light did not ignite immediately. Interviews with the Maintenance Director and the Administrator confirmed that the DM was primarily responsible for kitchen equipment maintenance, with the Maintenance Director serving as a backup. The Maintenance Director reported that all burners were functional during his last check on February 7, 2025, and suggested that grease might have clogged the pilot nozzle. He ordered a replacement part after being notified of the issue. The Administrator, who conducted weekly rounds, also confirmed that the burners were operational during his last inspection on February 2, 2025. Both the Maintenance Director and the Administrator emphasized the importance of staff reporting equipment issues promptly to ensure timely repairs.
Inaccurate MDS Coding for Insulin Use
Penalty
Summary
The facility failed to ensure accurate assessments for a resident, leading to an incorrect coding of the Minimum Data Set (MDS) for insulin use and injections. The resident, who was an elderly female with a history of hemiplegia, hypertension, and anxiety, did not have a diagnosis of diabetes mellitus nor any orders for insulin injections. Despite this, her quarterly MDS inaccurately indicated that she received insulin injections, which was not supported by her medical records or care plan. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON), confirmed that the resident had never received insulin or any type of injections. The ADON, who was responsible for completing the MDS, acknowledged the error and stated it would be corrected. The Director of Nursing (DON) also confirmed the incorrect coding and emphasized that such errors could lead to inappropriate resident care. The facility's policy on comprehensive assessments highlighted the importance of accurate coding to reflect the resident's clinical status, which was not adhered to in this case.
Inadequate Infection Control for Pleural Drain Bag
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper handling of a pleural drain bag for a resident with lung cancer, congestive heart failure, and high blood pressure. The resident, who had both long-term and short-term memory problems and was dependent on activities of daily living, was observed with their pleural drain bag and drain port on the floor under the bed. This observation was made despite the care plan indicating the need for enhanced barrier precautions related to the pleural drain. Interviews with facility staff, including an LVN, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that the pleural drain bag should not be on the floor to prevent infection and accidental dislodgement. The ADON, who also served as the infection control nurse, acknowledged the absence of a facility policy regarding the proper handling of pleural drain bags. The DON reiterated the expectation that the drain bag should be kept in a blue bag attached to the bed to prevent contamination. The lack of a formal policy and the improper placement of the drain bag on the floor represent a failure in the facility's infection control practices.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who was at high risk for falls. The resident, who had Alzheimer's, dementia, restless leg syndrome, and Parkinson's, experienced an unwitnessed fall resulting in a 3 cm laceration above her right eye. The incident occurred because the fall mat, which was supposed to be adjacent to her bed, was not in place at the time of the fall. The resident's care plan, which was supposed to include interventions to prevent falls, did not list a fall mat as an intervention despite the resident's high risk for falls. The care plan was not updated to include the fall mat even after a previous fall incident where the resident was found lying on her fall mat with a minor injury. Staff interviews revealed that there was a miscommunication and oversight in updating the care plan to include the fall mat. Staff members, including a CNA and LVN, acknowledged that the fall mat was moved away from the bed to facilitate the movement of the resident's Geri-chair and was not repositioned when the resident was transferred back to bed. The facility's policies on safety and supervision, as well as managing falls and fall risk, emphasize the importance of implementing and documenting interventions to reduce accident risks, which were not adhered to in this case.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). On the specified date, the Administrator overheard CNA F making intimidating remarks to a resident, instructing them to get up in a loud and inappropriate manner. The Administrator witnessed the incident and identified the CNA as the individual responsible for the verbal abuse. The resident involved in the incident was an elderly female with a history of dementia and schizophrenia, which affected her ability to make decisions and communicate effectively. Her care plan indicated she required supervision and assistance with activities of daily living (ADLs) and was dependent on staff for emotional and physical needs. The resident exhibited behavioral problems, including resistance to care, which may have contributed to the situation. The facility's investigation confirmed the verbal abuse incident, and the CNA involved had been trained on abuse prevention and resident rights. Despite this training, the CNA admitted to raising her voice due to having a bad day, although she denied using the specific language reported. The facility's records showed that the CNA was suspended and subsequently terminated following the incident.
Failure to Investigate and Report Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation and report the results of an incident involving a resident's fall within the required 5-day period. The resident, who had Alzheimer's, a right femur fracture, and a history of falling, experienced a fall in the lounge area. The fall was witnessed by staff, and the resident was subsequently sent to the emergency room for evaluation and treatment. Despite the incident being reported as neglect to the TULIP system, the facility did not complete an investigation or submit a 5-day report, as they believed the incident was not reportable due to it being witnessed. The Quality Assurance LVN and the Administrator both acknowledged that the report was made in error and attempted to have it deleted from the TULIP system. However, they did not follow up to ensure the report was actually removed. The facility's policy requires all reports of abuse, neglect, exploitation, or misappropriation to be thoroughly investigated and documented, but this was not adhered to in this case. The lack of investigation and reporting could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
Failure to Implement Comprehensive Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, who was at high risk for falls. The resident, diagnosed with Alzheimer's, dementia, restless leg syndrome, and Parkinson's, had a care plan that did not include the use of a fall mat, despite being at high risk for falls. This omission was evident in the care plan dated May 16, 2024, which listed several interventions but failed to mention the fall mat. The deficiency was highlighted by two incidents where the resident sustained injuries due to falls. On October 16, 2024, the resident was found lying on a fall mat with a small skin tear above her right eye, and on November 8, 2024, she was found on the floor with a 3 cm laceration above her right eye, requiring hospital treatment and sutures. Interviews with staff revealed that the fall mat was not consistently placed next to the resident's bed, contributing to the risk of injury. Interviews with facility staff, including the ADON, CNA, LVN, and the Administrator, confirmed that the care plan should have included a fall mat to prevent serious injuries. The staff acknowledged the oversight and the risk of serious injuries if fall mats were not in place. The facility's policies on safety, supervision, and care planning emphasized the importance of implementing and documenting specific interventions to reduce accident risks, which were not adhered to in this case.
Inadequate Supervision and Safety Measures for Smoking Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for residents who smoke, leading to a serious incident involving three residents. Resident #1, who was on oxygen therapy, was in a non-smoking area with Residents #2 and #3, both assessed as smokers. Resident #1's oxygen caught fire, resulting in multiple burns to her face, chest, and hands. The incident occurred because the residents were not in a designated smoking area, and there was no staff supervision present at the time. Resident #2 and Resident #3 were found to have kept smoking materials in their rooms, contrary to facility policy. Resident #2 was supposed to sign out his smoking supplies but did not comply, and staff were unaware of this non-compliance. Additionally, Resident #3 was not reassessed for smoking safety after the incident, and there was no updated Smoking-Safety Screen for either resident. The lack of proper assessments and supervision contributed to the unsafe conditions that led to the incident. Interviews with staff revealed a lack of awareness regarding which residents were smokers and who required supervision. There was no list of residents who smoked or required supervision, and staff were not consistently informed about residents' smoking statuses. This lack of communication and oversight resulted in residents smoking in non-designated areas without supervision, ultimately leading to the incident where Resident #1 sustained severe burns.
Failure to Ensure Smoking Safety Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to Federal, State, and Local laws and regulations regarding smoking safety, which resulted in a serious incident involving three residents. On the specified date, a resident who utilized oxygen was in a non-smoking area with two other residents who were assessed as smokers. The resident's oxygen caught on fire, leading to multiple burns on her face, chest, and hands. The facility did not ensure that the residents were smoking in a designated area, nor did they supervise the residents while they were smoking. Additionally, the facility failed to prevent residents from keeping smoking materials in their rooms. One resident admitted to keeping cigarettes and a lighter in his room, contrary to the facility's policy. The facility also did not reassess the residents for smoking safety after the incident, which was a critical oversight given the severity of the event. Interviews with staff revealed a lack of awareness regarding which residents were smokers and who required supervision, indicating a systemic failure in communication and policy enforcement. The incident highlighted the facility's inadequate smoking safety assessments and care planning. The residents involved had various medical conditions, including COPD and cognitive impairments, which should have necessitated stricter supervision and safety measures. The facility's failure to maintain up-to-date smoking safety assessments and care plans contributed to the unsafe environment that led to the incident.
Failure to Implement Comprehensive Smoking Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which included measurable objectives and timeframes to address their medical, nursing, mental, and psychosocial needs. Resident #1, a female with severe cognitive impairment and on oxygen therapy, did not have a care plan addressing tobacco use or smoking safety, despite being observed smoking a vape pen and attempting to smoke a cigarette while on oxygen. This oversight placed her at risk for unsafe smoking practices. Resident #2, a male with cognitive intactness, had a care plan for smoking that was not reviewed or updated when he refused to comply with the facility's smoking policy. He did not sign out to smoke off facility grounds and kept his smoking supplies in his room, contrary to the policy that required supervision and storage of smoking supplies at the nurses' station. The lack of updated assessments and care plans contributed to the staff's unawareness of his smoking habits and supervision needs. Resident #3, a female with cognitive intactness, had a care plan for smoking that was not updated after she was found with cigarettes and a lighter. Staff interviews revealed a lack of awareness regarding which residents smoked and their supervision requirements. The facility's failure to maintain a list of smokers and conduct regular smoking assessments led to inadequate supervision and increased the risk of unsafe smoking practices among residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rayburn Health Care & Rehabilitation | 15.5 mi | ★★★★★ | 8 | 0 |
| Avalon Place Kirbyville | 15.5 mi | ★★★★★ | 7 | 1 |
| Timberidge Nursing And Rehabilitation Center | 15.9 mi | ★★★★★ | 3 | 0 |
| Deridder Retirement & Rehab Center | 25.9 mi | ★★★★★ | 9 | 0 |
| Westwood Manor Nursing Home, Inc | 26.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Shady Acres Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.