Deficiencies (last 7 years)
Deficiencies (over 7 years)
8.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
68% occupied
Based on a September 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Sep 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a fall incident involving Resident #1 on 08/22/25, which resulted in injury and subsequent death. The investigation focused on the facility's protective oversight, fall prevention, pain management, and transfer procedures.
Complaint Details
The complaint investigation substantiated that the facility failed to provide adequate protective oversight and proper care following Resident #1's fall on 08/22/25, which led to injury and death on 08/30/25. The violation was initially classified as imminent danger Class I but was lowered to Class II after corrective actions.
Findings
The facility failed to provide adequate protective oversight for Resident #1, who was left unattended in a specialized wheelchair and experienced a fall causing injury and death. Staff lacked proper training in assessing injuries, managing pain, and transferring residents safely. The facility did not follow its own policies and procedures related to falls and pain management.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight for Resident #1 who was left unattended in a Broda chair, resulting in a fall with injury. Staff did not properly assess or manage the resident's pain or transfer the resident safely after the fall.
Report Facts
Facility census: 67
Dates related to incident: Aug 22, 2025
Dates related to incident: Aug 30, 2025
Inspection Report
Plan of Correction
Census: 75
Capacity: 75
Deficiencies: 1
Date: Jun 20, 2025
Visit Reason
The inspection was conducted to investigate deficiencies related to call light response times and resident dignity/privacy at Oxford Grand at Shoal Creek.
Findings
The facility failed to provide timely responses to call lights for three of four sampled residents, impacting their dignity and privacy. The facility census was 75, and no policy regarding call lights was in place.
Deficiencies (1)
19 CSR 30-88.010(29) Dignity/Privacy: Facility staff failed to provide proper and timely care for three residents by not answering call lights promptly. The facility lacked a policy regarding call lights.
Report Facts
Facility census: 75
Inspection Report
Plan of Correction
Census: 80
Deficiencies: 7
Date: May 14, 2025
Visit Reason
The inspection was conducted to identify deficiencies related to facility safety and sanitation, including electrical extension cord use and kitchen cleanliness, and to document the provider's plan of correction.
Findings
The facility was found to have multiple deficiencies including improper use of extension cords in resident rooms, unclean kitchen floors, walls, ceilings, vents, and food storage areas, and lack of policies regarding these issues. The facility census was 80 residents at the time of inspection.
Deficiencies (7)
19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles: The facility failed to prevent more than two appliances being served by one duplex receptacle in a resident room and lacked a policy on extension cord use.
19 CSR 30-87.020(12) Floor Surfaces: The facility failed to maintain clean floors in the kitchen, with food debris and sticky substances observed, and lacked a kitchen sanitation policy.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: The facility failed to keep the kitchen ceiling clean and free from dirt and debris, with a thick black speckled substance observed.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable: The facility failed to keep kitchen vent covers clean and free from dirt and debris, with vents corroded and covered with grime.
19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources: The facility failed to label and date food items in refrigerators, risking food safety.
19 CSR 30-87.030(55) Ventilation Hoods, Clean, Filters Removable: The facility failed to keep ventilation hood filters clean, with grease buildup observed and lack of a vent hood cleaning policy.
19 CSR 30-87.030(65) Nonfood Contact Surfaces, Cleaned as Needed: The facility failed to keep nonfood-contact surfaces clean, with grease, crumbs, and debris buildup on kitchen equipment and surfaces.
Report Facts
Facility census: 80
Inspection Report
Plan of Correction
Census: 72
Deficiencies: 3
Date: Jan 14, 2025
Visit Reason
The inspection was conducted to assess compliance with state regulations related to resident care and food safety at Oxford Grand at Shoal Creek.
Findings
The facility failed to assist a resident with showering as per their individualized service plan and failed to properly thaw and maintain food at safe temperatures during meal service. These deficiencies potentially affected all residents.
Deficiencies (3)
19 CSR 30-86.047(38) Assist to be Clean & Odor Free. The facility failed to encourage and assist a resident to be clean and free of body and mouth odor as required by their individualized service plan.
19 CSR 30-87.030(33) Thawing Potentially Hazardous Foods. The facility failed to thaw potentially hazardous foods in a safe manner, submerging chicken breasts and ground beef in water improperly.
19 CSR 30-87.030(34) Food-120 Degrees/Above, 45 Degrees/Below. The facility failed to maintain food at a sufficient temperature during meal service, serving food below the required 120 degrees Fahrenheit.
Report Facts
Facility census: 72
Sampled residents: 7
Chicken breasts: 25
Ground beef weight (lbs): 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LIMA A | Level One Medication Aide | Mentioned in relation to resident assistance with showering |
| Director of Nursing | Interviewed regarding resident assistance and baseline expectations | |
| Administrator | Interviewed regarding staff assistance expectations | |
| Cook A | Interviewed regarding knowledge of proper thawing and food temperature | |
| Dining Director | Educated on thawing and food temperature procedures |
Inspection Report
Plan of Correction
Census: 76
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
The inspection was conducted to assess compliance with medication administration regulations and to identify deficiencies related to the facility's medication system.
Findings
The facility failed to develop and implement a safe and effective medication control and use system, resulting in missed medication doses for multiple residents. Documentation and timely reordering of medications were inadequate.
Deficiencies (1)
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to develop and implement a safe and effective medication control and use system, resulting in missed medications for four of seven sampled residents. The facility census was 76.
Report Facts
Resident census: 76
Missed doses: 13
Inspection Report
Plan of Correction
Census: 76
Deficiencies: 2
Date: Oct 11, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to resident discharge appeal rights and abuse prevention at Oxford Grand at Shoal Creek, including review of incidents involving resident safety and discharge procedures.
Findings
The facility failed to provide adequate discharge notices including appeal rights and discharge location for Resident #2, and failed to protect Resident #1 from physical and verbal abuse by Resident #2. The facility census was 76 at the time of inspection. The facility implemented corrective actions to address these issues.
Deficiencies (2)
19 CSR 30-68.010(17) Discharge Appeal Rights: The facility failed to provide full and adequate written notice of discharge including appeal rights and discharge location for Resident #2. The discharge notice lacked required information and the resident was discharged without a secured place to go.
19 CSR 30-88.010(22) Free From Abuse: The facility failed to ensure Resident #1 was free from physical and verbal abuse by Resident #2, and did not put interventions in place to protect Resident #1 from abuse incidents occurring on multiple dates.
Report Facts
Facility census: 76
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 20, 2024
Visit Reason
The inspection was conducted to assess compliance with fire safety regulations, specifically regarding range hood extinguishing systems and smoke section partitions in a licensed facility with more than 20 beds.
Findings
The facility failed to maintain the range hood extinguishing system according to NFPA 96 standards and did not ensure smoke stop partition doors properly closed during a fire alarm. Both issues potentially affected all 83 residents.
Deficiencies (2)
19 CSR 30-86.022(4)(B)(1)(2) Range Hood-After 7/11/80 & Before 10/1/00: The facility failed to have the range hood extinguishing system maintained and certified annually as required by NFPA 96, 1998 edition. The inspection tag was expired by about three months.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: The facility failed to ensure smoke stop partition doors properly closed during a fire alarm due to the door hitting the frame and not closing properly.
Report Facts
Facility census: 83
Licensed beds: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding corrective actions for range hood extinguishing system and smoke partition doors |
Inspection Report
Plan of Correction
Census: 80
Deficiencies: 4
Date: May 10, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Oxford Grand at Shoal Creek following a survey conducted on 05/10/2024. The visit was to assess compliance with assisted living facility regulations, including individual service plans, resident condition reviews, food safety, and cleanliness.
Findings
The facility failed to ensure individual service plans were reviewed and updated after significant changes in residents' conditions, and failed to accurately review residents' general conditions and needs monthly. Food safety violations included storing food without proper labeling and dating. Nonfood-contact surfaces were not cleaned adequately. These deficiencies had the potential to affect all residents.
Deficiencies (4)
19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements. The facility failed to review and update individual service plans for residents after significant condition changes, including falls, for three of eight sampled residents. The facility census was 80.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review. The facility failed to accurately review each resident's general condition and needs monthly, including incidents that could cause injury, for two of eight sampled residents. The facility census was 80.
19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources. The facility failed to ensure food was in sound condition, free from spoilage, and properly labeled and dated. Observations included unlabeled and undated food items. The facility census was 80.
19 CSR 30-87.030(65) Nonfood Contact Surfaces, Cleaned as Needed. The facility failed to ensure nonfood-contact surfaces of equipment were clean and free from accumulation of dust, dirt, food particles, and debris. Observations included grease and food buildup on kitchen equipment. The facility census was 80.
Report Facts
Facility census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Care Team Supervisor A | Entered progress notes related to resident falls and conditions | |
| Director of Nursing | DON | Interviewed regarding review and updating of individual service plans and resident condition documentation |
| Assistant Director of Nursing | ADON | Responsible for completing and updating individual service plans and resident condition documentation |
| Administrator | Interviewed regarding policies for reviewing and updating individual service plans and resident condition documentation | |
| LIMA A | Level One Medication Aide | Observed assisting resident with walker and chair |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jun 28, 2023
Visit Reason
The inspection was conducted to assess compliance with personnel record requirements, resident condition and medication review, and food storage regulations at Oxford Grand at Shoal Creek.
Findings
The facility failed to maintain complete personnel records including background checks, did not complete required monthly summaries for residents, and stored food improperly on the floor of the walk-in freezer.
Deficiencies (3)
19 CSR 30-86.047(20)(G) Personnel Record - Waiver: The facility failed to maintain an individual personnel record including background check results for one of three sampled employees. The facility census was 75.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: The facility failed to ensure monthly summaries were completed for four of five sampled residents. The facility census was 48.
19 CSR 30-87.030(15) Food-Stored Above the Floor, Protected: The facility failed to ensure food was stored above the floor to protect it from contamination when boxes of food were stored on the floor of the walk-in freezer. The facility census was 75.
Report Facts
Facility census: 75
Facility census: 48
Sampled residents missing monthly summaries: 4
Boxes of food stored on floor: 3
Inspection Report
Plan of Correction
Census: 72
Deficiencies: 7
Date: May 25, 2023
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a state survey conducted on 05/25/2023 at Oxford Grand at Shoal Creek.
Findings
The facility failed to meet multiple fire safety and life safety code requirements, including fire safety training for employees, exits and stairways maintenance, fire alarm system monthly testing, door self-closing devices, smoke section partitions, sprinkler system maintenance, and wastebasket compliance. These deficiencies potentially affected all 72 residents present during the survey.
Deficiencies (7)
19 CSR 30-86.022(6)(A)(1-3) Fire Safety Training Requirements-employees. The facility failed to maintain training on the use of the area of refuge and its communication system for staff in the memory care area.
19 CSR 30-86.022(7)(A)(2) Exits/Stairways After 12/31/87. The facility failed to ensure at least two unobstructed exits remote from each other were maintained, with exit doors taped with signs stating 'this is not an exit'.
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test. The facility failed to produce documentation of monthly fire alarm activations for several months.
19 CSR 30-86.022(10)(G) Door Devices - Self/Auto closing. The facility failed to ensure doors providing separation between floors were held open only with functioning electromagnetic hold-open devices.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to ensure smoke stop partition doors properly closed during fire alarm activation.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13. The facility failed to do monthly pressure gauge readings and valve position checks of the sprinkler system.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to ensure all wastebaskets were the approved types allowed.
Report Facts
Facility census: 72
Inspection Report
Plan of Correction
Census: 80
Deficiencies: 1
Date: Jun 30, 2022
Visit Reason
The inspection was conducted to assess compliance with protective oversight regulations, specifically regarding the use of low air loss mattresses (LALM) and side rails for residents.
Findings
The facility failed to ensure proper protective oversight by not completing side rail assessments, not obtaining physician's orders for LALM use, and not updating individualized service plans for six sampled residents. There was also a lack of policies and staff training related to the use of side rails, LALM, and bolsters.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight was not met as the facility failed to complete side rail assessments and obtain physician's orders for low air loss mattresses for six sampled residents. Individualized Service Plans were not updated to reflect the use of these devices.
Report Facts
Facility census: 80
Number of sampled residents with deficiencies: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding training and policies on LALM, side rails, and bolsters |
| Memory Care Supervisor | Memory Care Supervisor | Interviewed about side rail placement and family communication |
| Certified Nursing Assistant A | Certified Nursing Assistant (CNA) | Interviewed about resident LALM settings and training |
| Certified Nursing Assistant B | Certified Nursing Assistant (CNA) | Interviewed about mattress testing and training on LALM and side rails |
| Hospice Nurse | Hospice Nurse | Interviewed about hospice assessments and safety evaluations |
Inspection Report
Plan of Correction
Census: 80
Deficiencies: 1
Date: May 26, 2022
Visit Reason
The document is a plan of correction related to a deficiency found during an inspection on 05/26/2022 regarding wastebasket compliance.
Findings
The facility failed to ensure all wastebaskets were metal or UL- or FM-fire-resistant rated as required. Observations showed multiple rooms had non-approved wastebaskets, potentially affecting all 80 residents.
Deficiencies (1)
19 CSR 30-86.022(15)(A) Wastebaskets must be metal or UL- or FM-fire-resistant rated. The facility failed to ensure all wastebaskets met this requirement, with non-approved types found in multiple rooms.
Report Facts
Facility census: 80
Residents potentially affected: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed on 5/26/22 regarding corrective actions for wastebasket compliance |
Inspection Report
Census: 72
Deficiencies: 2
Date: May 18, 2021
Visit Reason
The inspection was a licensure inspection including a fire safety portion conducted on May 18, 2021.
Findings
The facility failed to properly maintain delayed egress doors and failed to ensure all wastebaskets were metal or fire-resistant rated as required by fire safety regulations.
Deficiencies (2)
19 CSR 30-86.022(7)(E) Locked Exit Doors: The facility failed to properly maintain delayed egress doors to comply with NFPA 101 standards. The North delayed exit door in the Glen memory care unit was missing most of the required signage.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility failed to ensure all wastebaskets were metal or UL/FM fire-resistant rated. Multiple rooms contained improper wastebaskets.
Report Facts
Facility census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding locked exit doors and wastebasket issues |
Inspection Report
Plan of Correction
Census: 69
Deficiencies: 6
Date: Apr 29, 2021
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Oxford Grand at Shoal Creek following a survey conducted on 04/29/2021. The purpose is to identify regulatory deficiencies and outline corrective actions.
Findings
The facility was found deficient in maintaining cleanliness of walls, ceilings, doors, windows, and vents; proper food storage and labeling; use of pasteurized eggs; chemical sanitization monitoring; and resident rights related to room access and control. Multiple Class II and Class III violations were cited.
Deficiencies (6)
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean. The facility failed to keep the kitchen window and window seal clean and free from dirt and debris.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable. The facility failed to keep vent covers in the kitchen clean and free from dirt and debris.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS. The facility failed to ensure food was stored in sealed, labeled, dated containers off the floor.
19 CSR 30-87.030(28) Whole/Pasteurized Eggs Used Only. The facility failed to ensure only pasteurized eggs were served for cooking.
19 CSR 30-87.030(81) Machine Chemical Sanitization, PPM Measured. The facility failed to ensure staff checked the chemical concentration of the sanitizer in the dishwasher and maintain documentation.
19 CSR 30-88.010(41) Resident Lives Not Regulated/Controlled. The facility failed to ensure residents did not have their personal lives controlled beyond reasonable adherence, including locking resident rooms and restricting access.
Report Facts
Facility census: 69
Inspection Report
Plan of Correction
Census: 69
Deficiencies: 3
Date: Jan 5, 2021
Visit Reason
The inspection was conducted to assess compliance with criminal background check requirements, medication storage and accessibility, and safe and effective medication system regulations at Oxford Grand at Shoal Creek.
Findings
The facility failed to conduct criminal background checks for one employee, failed to ensure all medications were stored securely behind locked doors or cabinets, and failed to develop and implement a safe and effective medication system for sampled residents.
Deficiencies (3)
A4711 Criminal Background Check Requirements: The facility failed to conduct a criminal background check for one of three sampled employees prior to employment. This had the potential to affect all residents.
A4782 Medication Storage/Accessibility: The facility failed to ensure all medications were stored in a secured location behind at least one locked door or cabinet. Observations showed medication room doors propped open and unlocked treatment carts.
A4797 Safe & Effective Medication System: The facility failed to develop and implement a safe and effective medication system for one of six sampled residents. Medication errors were observed including incorrect medication administration and lack of re-education for staff.
Report Facts
Facility census: 69
Number of sampled employees: 3
Number of sampled residents: 6
Inspection Report
Annual Inspection
Census: 77
Capacity: 77
Deficiencies: 5
Date: Jun 4, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state regulations for long-term care facilities.
Findings
The facility was found deficient in multiple areas including tuberculosis screening for staff, medication system safety, hair restraints for food service staff, chemical sanitization procedures, and resident rights annual review. Several deficiencies were classified as Class II or Class III violations.
Deficiencies (5)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to maintain compliance by not screening two of five sampled employees for tuberculosis within one month prior to employment.
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to properly account for and dispose of outdated medications for two of 12 sampled residents.
19 CSR 30-87-030(3) Clean Clothing, Hair Restraints: Staff failed to secure hair and beard with effective hair restraints to prevent contamination of food or food-contact surfaces.
19 CSR 30-87-030(74) Chemical Sanitization, PPM Measured: The facility failed to ensure staff checked and documented the chemical concentration of sanitizing solutions used in the dishwasher and for cleaning rags.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: The facility failed to review resident rights annually with four of six sampled residents.
Report Facts
Facility census: 77
Deficiencies cited: 5
Inspection Report
Plan of Correction
Census: 74
Deficiencies: 2
Date: May 10, 2019
Visit Reason
The inspection was conducted as part of a fire safety portion of the licensure inspection to ensure compliance with regulations regarding wastebaskets and portable heaters.
Findings
The facility failed to ensure all wastebaskets were metal or UL- or FM-fire-resistant rated, and portable heaters were not prohibited as required. These issues affected all 74 residents.
Deficiencies (2)
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility used non-approved wastebaskets in multiple rooms, affecting all 74 residents.
19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable: The facility failed to prohibit portable space heaters, evidenced by a portable electric heater found in Room 117.
Report Facts
Facility census: 74
Residents affected: 74
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 6
Date: Sep 21, 2018
Visit Reason
The inspection was the annual licensure inspection including fire safety and regulatory compliance at Oxford Grand at Shoal Creek.
Findings
The facility failed to post proper signage for areas of refuge, did not ensure smoke section partitions properly closed, used non-approved wastebaskets, failed to provide adequate oxygen storage racks, improperly used extension cords in resident rooms, and lacked current approved boiler inspection certifications. Corrective actions and plans of correction were documented for each deficiency.
Deficiencies (6)
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements. The facility failed to post proper signage 'AREA OF REFUGE IN CASE OF FIRE' at all entrances to areas of refuge on the second floor.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to ensure smoke stop partition doors properly closed during a fire alarm, with doors rubbing on frames preventing closure.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to ensure all wastebaskets were approved metal or UL/FM fire-resistant types.
19 CSR 30-86.022(17) Oxygen Storage Requirements. The facility failed to provide enough oxygen storage racks in the oxygen storage room for the oxygen bottles.
19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles. The facility failed to limit use to only two electrical items in duplex receptacles in resident rooms, with one room having four items plugged in.
State Statute 9998. The facility failed to have current approved boiler inspection certifications for hot water tanks as required under state statute 11CSR40-2.022.
Report Facts
Facility census: 57
Facility census: 4
Water heater input rating: 399999
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