Cycle 1
Health 2025-09-05 · Fire 2025-09-05
4 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Moulton, TX
Shady Oak Nursing And Rehabilitation
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
101 S Lancaster, Moulton, TX
(361) 596-7373
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
61
Certified beds
Average residents
32
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
1980-12-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
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
0.36
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.63
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,199
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
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
0
Performance 62.07% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.54
Baseline 3.84 hours · Performance 4.08 hours · Measure score 3.54 · Achievement 3.54 · Improvement 0.77
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.59% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 13.16% · Lower 95% interval 7.2% |
| Discharge to community | 27.5% |
50.57%
23.1 pts worse
|
Worse than the National Rate · Eligible stays 26 · Observed rate 7.69% · Lower 95% interval 17.61% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 8% |
2.29%
5.7 pts worse
|
Numerator 2 · Denominator 25 · Adjusted rate 8.98% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 48 |
| Staff flu vaccination coverage | 44.29% |
42%
2.3 pts better
|
Numerator 31 · Denominator 70 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · 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 | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.3%
0.6 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 6.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
2.7%
1.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
3.3%
1.2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 4.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
18.9%
3.9 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 16.7% · Q3 15.4% · Q4 11.1% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
10.8%
3.9 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 8.7% · Q3 4.5% · Q4 12.5% · 4Q avg 6.9% · 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 | 7.1% |
15.4%
8.3 pts better
|
16.3%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.4% |
16.1%
7.7 pts better
|
14.9%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 8.7% · Q3 12.0% · Q4 7.7% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
15.0%
6.4 pts worse
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 21.6% · Q3 17.3% · Q4 18.1% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.2%
2 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 4.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
89.7%
7.3 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 100.0% · 4Q avg 97.0% |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
2 health deficiencies
Top issue: Environmental (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-14 · Fire 2023-07-14
8 health deficiencies
Top issue: Administration (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-09-26
E · Potential for more than minimal harm
2025-09-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-10-19
D · Potential for more than minimal harm
2025-09-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-10
F · Potential for more than minimal harm
2024-08-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-08-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-08-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-09
F · Potential for more than minimal harm
2023-07-14
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-07-14
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-07-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-07-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-19
C · Minimal harm
2023-07-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-09-05
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 2025-09-08
D · Potential for more than minimal harm
2025-09-05
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-09-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-09-08
E · Potential for more than minimal harm
2024-08-08
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-09
F · Potential for more than minimal harm
2023-07-14
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2023-08-09
E · Potential for more than minimal harm
2023-07-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-09
E · Potential for more than minimal harm
2023-07-14
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-08-09
E · Potential for more than minimal harm
2023-07-14
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2023-08-09
E · Potential for more than minimal harm
2023-07-14
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-07-14
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-07-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-07-14
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-08-09
Penalties and ownership
What sits behind the stars
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Huggins, Linda
Corporate Director · Individual
Moulton I Enterprises LLC
Operational/Managerial Control · Organization
Thompson, Johnny
Corporate Officer · Individual
Willig, Zachary
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Flatonia Healthcare Center
Flatonia, TX
2-star overall rating with 2-star inspections with abuse icon flag with $23,005 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Shiner Nursing And Rehabilitation Center Inc
Shiner, TX
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Hallettsville Nursing And Rehabilitation
Hallettsville, TX
3-star overall rating with 4-star inspections with $8,824 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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