Cycle 1
Health 2025-02-12 · Fire 2025-02-12
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Newton, TX
Shady Acres Health and Rehabilitation Center
1-star overall rating with 1-star inspections with abuse icon flag with $167,925 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
405 Shady Acres Lane, Newton, TX
(409) 379-8911
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-06-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.30
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.88
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
38%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,417
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.11
Baseline 62.50% · Performance 50.98% · Measure score 3.11 · Achievement 3.11 · Improvement 2.56
Adjusted total nurse staffing
2.85
Baseline 3.26 hours · Performance 3.89 hours · Measure score 2.85 · Achievement 2.85 · Improvement 2
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.64% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 27.59% · Lower 95% interval 8.62% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.42 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 81.82% |
95.27%
13.5 pts worse
|
Numerator 18 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 9.09% |
2.29%
6.8 pts worse
|
Numerator 2 · Denominator 22 · Adjusted rate 10.98% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
97.1%
1.8 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.8% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
97.9%
6.2 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 45.3% |
2.7%
42.6 pts worse
|
11.4%
33.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.9% · Q2 51.2% · Q3 51.2% · Q4 44.2% · 4Q avg 45.3% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
3.3%
1.7 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 45.7% |
18.9%
26.8 pts worse
|
19.6%
26.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 54.3% · Q3 42.9% · Q4 40.5% · 4Q avg 45.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.5% |
10.8%
6.7 pts worse
|
16.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 16.7% · Q3 16.7% · Q4 14.8% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.8% |
15.4%
9.4 pts worse
|
16.3%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.4% |
16.1%
6.3 pts worse
|
14.9%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 25.8% · Q3 21.9% · Q4 25.0% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.1% |
0.5%
3.6 pts worse
|
1.0%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.1% · Q3 5.3% · Q4 3.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.6% |
0.8%
8.8 pts worse
|
1.7%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.3% · Q3 14.3% · Q4 12.8% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.1% |
15.0%
7.9 pts better
|
19.8%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 5.0% · Q3 0.0% · Q4 3.7% · 4Q avg 7.1% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.2%
0.4 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 8.3% · Q3 3.0% · Q4 1.7% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
89.7%
8 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 90.0% · 4Q avg 97.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.0% |
88.0%
16 pts worse
|
79.7%
7.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-20 · Fire 2023-12-20
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-10-19 · Fire 2022-10-19
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-03
F · Potential for more than minimal harm
2025-02-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-02-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-02-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-10
C · Minimal harm
2025-02-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2023-12-20
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-02-21
E · Potential for more than minimal harm
2023-12-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-21
D · Potential for more than minimal harm
2023-12-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-21
D · Potential for more than minimal harm
2023-12-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-21
D · Potential for more than minimal harm
2023-12-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-21
D · Potential for more than minimal harm
2023-12-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-21
D · Potential for more than minimal harm
2023-12-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-21
D · Potential for more than minimal harm
2023-12-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-21
C · Minimal harm
2023-12-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2022-10-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-10-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-10-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-11
C · Minimal harm
2022-10-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Inspection history
Recent health citations
J · Immediate jeopardy
2025-12-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-12-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-01
K · Immediate jeopardy
2025-10-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-07
K · Immediate jeopardy
2025-10-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-07
K · Immediate jeopardy
2025-10-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-02-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-02-12
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-10
G · Actual harm
2024-12-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-12-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-14
J · Immediate jeopardy
2024-07-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-27
J · Immediate jeopardy
2024-07-26
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2024-07-27
E · Potential for more than minimal harm
2024-07-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-27
F · Potential for more than minimal harm
2023-12-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-12-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-15
D · Potential for more than minimal harm
2023-12-20
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-12-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-12-20
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-02-01
E · Potential for more than minimal harm
2022-10-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-10-19
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-10-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-11-09
Penalties and ownership
What sits behind the stars
$26,685
2025-12-11
Fine
Fine · fine $26,685
Fine
$40,650
2025-10-23
Fine
Fine · fine $40,650
Fine
$17,692
2024-12-20
Fine
Fine · fine $17,692
Fine
$82,898
2024-07-26
Fine
Fine · fine $82,898
Fine
Ownership
Nathan Hines Estate
5% Or Greater Indirect Ownership Interest · Organization
Hines, Ross
5% Or Greater Direct Ownership Interest · Individual
Hines, Ross
Operational/Managerial Control · Individual
Hines, Ross
Corporate Director · Individual
Hines, Ross
Corporate Officer · Individual
Hines, Ross
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Rayburn Health Care & Rehabilitation
Jasper, TX
4-star overall rating with 4-star inspections with 7 recent health deficiencies
#2
Avalon Place Kirbyville
Kirbyville, TX
5-star overall rating with 4-star inspections with $14,020 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Timberidge Nursing And Rehabilitation Center
Jasper, TX
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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