Inspection Reports for
Shady Oaks Healthcare Center
335 BUSINESS ROUTE 63, THAYER, MO, 65791-1415
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
54% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 65
Deficiencies: 3
Date: Dec 5, 2025
Visit Reason
The inspection was conducted to assess compliance with medication administration, drug labeling and storage, and infection prevention and control practices at Shady Oaks Healthcare Center.
Findings
The facility failed to maintain medication error rates below five percent, improperly labeled and stored medications including expired insulin pens, and did not consistently implement enhanced barrier precautions for residents with wounds or indwelling devices.
Deficiencies (3)
F 0759: The facility failed to maintain a medication error rate below five percent during insulin administration, with two errors in 32 opportunities affecting two residents. Certified Medication Technicians did not properly prime insulin pens as per manufacturer guidelines.
F 0761: The facility failed to ensure drugs and biologicals were labeled and stored according to accepted professional principles, including use of expired insulin pens and unlabeled opened medications.
F 0880: The facility failed to provide and implement an infection prevention and control program by not using enhanced barrier precautions consistently for residents with wounds or indwelling devices, including failure to wear gowns during wound care.
Report Facts
Medication administration opportunities: 32
Medication errors: 2
Medication error rate: 6.25
Facility census: 65
Expired insulin pen days past expiration: 79
Expired insulin pen days past expiration: 65
Medication expiration period: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Failed to prime insulin lispro-aabc pen before administration |
| CMT B | Certified Medication Technician | Failed to prime Humalog Kwikpen before administration |
| RN C | Registered Nurse | Described insulin pen priming procedures |
| DON | Director of Nursing | Provided expectations on medication error rates and insulin pen administration |
| RN D | Registered Nurse | Explained labeling and expiration requirements for insulin pens and tuberculin vials |
| CNA J | Certified Nurse Assistant | Did not wear gown during incontinent care for resident requiring enhanced barrier precautions |
| LPN G | Licensed Practical Nurse | Did not wear gown during wound care for resident requiring enhanced barrier precautions |
| CNA E | Certified Nurse Assistant | Described use of gowns and signage for residents on enhanced barrier precautions |
| IP | Infection Preventionist | Implemented enhanced barrier precautions and explained exceptions |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 6
Date: Aug 1, 2024
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for Shady Oaks Healthcare Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper use of psychotropic medications, qualified dietary staff, food safety and sanitation, infection prevention and control, and pest control. Several deficiencies were cited with varying severity levels.
Deficiencies (6)
F584 Safe Environment: The facility failed to provide a safe, clean, and comfortable homelike environment, evidenced by dirt, debris, dead flies on windows, black grime buildup in shower rooms, and inadequate cleaning practices.
F758 Psychotropic Drugs: The facility failed to ensure appropriate diagnoses for psychotropic medication use for five residents and lacked a policy for medication management.
F801 Staffing: The facility failed to employ a qualified director of food and nutrition services and did not maintain cleanliness or control pests in the kitchen.
F812 Food Safety: The facility failed to procure, store, prepare, and serve food under sanitary conditions, with buildup of dirt and debris in kitchen areas and inadequate documentation of food temperatures.
F880 Infection Control: The facility failed to maintain infection control practices, including proper glove use during catheter care and wound care, and failed to prevent transmission of infections.
F925 Pest Control: The facility failed to maintain an effective pest control program, evidenced by multiple flies in kitchen and dining areas.
Report Facts
Facility census: 64
Residents sampled for psychotropic medication review: 16
Residents with inappropriate psychotropic medication use: 5
Completion dates for plan of correction: Most corrective actions due by 2024-09-09
Inspection Report
Life Safety
Census: 64
Deficiencies: 3
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and related standards at Shady Oaks Healthcare Center.
Findings
The facility failed to meet several Life Safety Code requirements including grease buildup in the kitchen range hood and HVAC vents, inadequate maintenance of the sprinkler system, and improper storage of oxygen cylinders. These deficiencies posed potential fire hazards and risks to occupants.
Deficiencies (3)
K324 Cooking Facilities: The facility failed to ensure the kitchen range hood was free of grease buildup, which added to the fire load of the zone.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system free of corrosion and debris, delaying fire device activation.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to adequately store oxygen cylinders, with doors left open and improper segregation of empty and full tanks.
Report Facts
Facility census: 64
Inspection Report
Routine
Census: 64
Deficiencies: 6
Date: Aug 1, 2024
Visit Reason
Routine inspection of Shady Oaks Healthcare Center to assess compliance with regulatory standards including environment safety, medication use, staffing qualifications, food service, infection control, and pest control.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, appropriate psychotropic medication diagnoses, qualified dietary management, sanitary food storage and preparation, infection control practices during wound and catheter care, and effective pest control to manage flies in the kitchen and dining areas.
Deficiencies (6)
F 0584: Facility failed to provide a safe, clean, and comfortable homelike environment with dirt, debris, dead flies on window ledges, and grime in shower rooms with cracked tiles and unapproved shower hose.
F 0758: Facility failed to ensure appropriate diagnoses for psychotropic medication use for five sampled residents and one non-sampled resident, lacking documentation to justify medication orders.
F 0801: Facility failed to employ a qualified director of food and nutrition services; the Dietary Manager lacked required experience and certification.
F 0812: Facility failed to maintain sanitary food storage and preparation areas, with dirty floors, debris, pest presence, undocumented food temperatures, and incomplete cleaning logs.
F 0880: Facility failed to maintain infection control during wound care and catheter care, including improper glove use, contaminated treatment carts, and failure to follow clean technique.
F 0925: Facility failed to maintain an effective pest control program, resulting in a fly infestation in the kitchen and dining areas affecting resident meals and environment.
Report Facts
Facility census: 64
Sampled residents for psychotropic medication review: 16
Residents affected by psychotropic medication deficiency: 6
Dietary Manager hire date: Dec 1, 2022
Dates of pest control inspection reports: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Named in infection control deficiency for improper wound care and treatment cart handling |
| LPN K | Licensed Practical Nurse | Named in infection control deficiency for improper glove use during wound care |
| Dietary Manager | Dietary Manager | Named in deficiency for lack of required certification and oversight of food service sanitation |
| Administrator | Facility Administrator | Interviewed regarding facility policies and deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding psychotropic medication use |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding window cleaning and pest control responsibilities |
| RN E | Registered Nurse | Interviewed regarding infection control expectations |
| CNA G | Certified Nursing Assistant | Named in catheter care infection control deficiency |
| CNA I | Certified Nursing Assistant | Named in catheter care infection control deficiency |
Inspection Report
Deficiencies: 0
Date: May 11, 2023
Visit Reason
The inspection was conducted as a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 0
Date: May 11, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 10
Date: Jan 24, 2023
Visit Reason
The document is a Plan of Correction submitted by Shady Oaks Healthcare Center following a survey conducted from January 22 to January 24, 2023. It addresses deficiencies identified during the inspection.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, accuracy of resident assessments, respiratory care and oxygen administration, and proper labeling and storage of drugs and biologicals. Specific issues included damaged wheelchair arm pads, discolored ceiling tiles, inaccurate Minimum Data Set coding, oxygen administration errors, and improper medication labeling.
Deficiencies (10)
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to provide a safe, clean, and comfortable homelike environment, including damaged wheelchair arm pads and discolored ceiling tiles that could injure residents.
F641 Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set for three sampled residents, resulting in inaccurate documentation of diagnoses and wound staging.
F695 Respiratory/Tracheostomy Care and Suctioning. The facility failed to follow physician's orders for supplemental oxygen therapy for two residents, administering oxygen at incorrect flow rates.
F761 Label/Store Drugs and Biologicals. The facility failed to ensure drugs and biologicals were labeled and stored according to accepted practices, including unlabeled opened medication vials and expired insulin pens.
A3038 Furniture/Equip, Provide Comfort & Safety. The facility failed to maintain furniture and equipment in good condition, including broken and heavily soiled items affecting resident safety.
A4054 Written Orders; Restraints. The facility failed to provide medication, treatment, or diet without a lawful written order, violating resident rights.
A4062 Medication Labeling. The facility failed to label all prescription medications in accordance with professional standards and state and federal laws.
A6012 Floor Surfaces. The facility failed to maintain all floors and floor coverings in good repair and cleanliness.
A6015 Walls/Ceilings/Doors/Windows Clean. The facility failed to maintain walls, ceilings, doors, windows, and skylights in good repair and cleanliness.
A6045 Lavatory/Fixtures Clean/Good Repair. The facility failed to keep lavatories, soap dispensers, and hand-drying devices clean and in good repair.
Report Facts
Facility census: 54
Deficiencies cited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leigh Kindelsee | Administrator | Signed the plan of correction and referenced in findings |
| Director of Nursing | Mentioned in interviews related to resident assessments and oxygen administration | |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding oxygen order and administration |
| Certified Nurse Aide C | Certified Nurse Aide | Interviewed about maintenance requests |
| Certified Nurse Assistant E | Certified Nurse Assistant | Interviewed about resident oxygen adjustment |
| Certified Nurse Assistant F | Certified Nurse Assistant | Interviewed about resident oxygen concentrator use |
| Certified Nurse Assistant G | Certified Nurse Assistant | Interviewed about resident oxygen concentrator use |
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 2
Date: Jan 24, 2023
Visit Reason
The document is a plan of correction submitted following a survey conducted from January 22 to January 24, 2023, addressing deficiencies related to emergency lighting at Shady Oaks Healthcare Center.
Findings
The facility failed to maintain adequate emergency egress lighting, potentially affecting all residents and staff. Insufficient emergency lighting was observed along the exit egress pathway from the courtyard on January 23, 2023.
Deficiencies (2)
K281: The facility failed to maintain emergency egress lighting as required by NFPA 101, resulting in insufficient illumination along the exit egress pathway. This deficiency potentially affected all residents and staff.
A2050: Facilities must have emergency lighting of sufficient intensity for safety of residents and others using exits, stairways, and corridors. This regulation was not met as evidenced by the K281 deficiency.
Report Facts
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leigh Kindred | RN, LNHA Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 4
Date: Jan 24, 2023
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with federal regulations and facility policies related to resident safety, care, and facility maintenance.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, accurate resident assessments, appropriate respiratory care, and proper labeling and storage of drugs and biologicals. Several maintenance issues and medication coding inaccuracies were identified, along with improper oxygen therapy administration and unlabeled medications.
Deficiencies (4)
F 0584: The facility failed to provide a safe, clean, and comfortable environment, with damaged wheelchair arm pads and ceiling and floor tiles that could injure residents.
F 0641: The facility failed to accurately code the Minimum Data Set (MDS) for three residents, including incorrect medication and diagnosis coding.
F 0695: The facility failed to follow physician's orders for supplemental oxygen therapy for two residents, administering oxygen at incorrect flow rates.
F 0761: The facility failed to ensure drugs and biologicals were labeled according to accepted practices, with unlabeled insulin pens and tuberculosis test vials.
Report Facts
Facility census: 54
Residents sampled for MDS accuracy: 14
Residents affected by MDS coding deficiency: 3
Residents affected by oxygen therapy deficiency: 2
Opened Lantus insulin pen date: Dec 15, 2022
Date of physician order for oxygen: Jun 6, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Assistant | Interviewed about maintenance request procedures | |
| Certified Nurse Aide (CNA) C | Interviewed about maintenance request procedures | |
| Administrator | Interviewed about maintenance and MDS coding expectations | |
| Certified Nurse Aide (CNA) A | Interviewed about maintenance reporting | |
| Director of Nursing (DON) | Interviewed about MDS coding and oxygen therapy expectations | |
| MDS Coordinator | Interviewed about MDS coding accuracy | |
| Licensed Practical Nurse (LPN) D | Interviewed about oxygen order and administration | |
| Certified Nurse Assistant (CNA) E | Interviewed about resident oxygen use | |
| Certified Nurse Assistant (CNA) F | Interviewed about resident oxygen use | |
| Certified Nurse Assistant (CNA) G | Interviewed about resident oxygen use | |
| Licensed Practical Nurse (LPN) B | Interviewed about medication labeling |
Inspection Report
Routine
Deficiencies: 0
Date: Nov 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 19, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess the facility's compliance with related CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 7
Date: Feb 21, 2020
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for Shady Oaks Healthcare Center.
Findings
The facility was found to have multiple deficiencies related to comprehensive care plans, free of accident hazards, drug regimen review, psychotropic medication use, food safety, and handrails. The facility census was 64 at the time of inspection.
Deficiencies (7)
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement care plans with specific interventions tailored to meet individual needs for two residents. The facility census was 64.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure proper transfer technique for one resident, risking accident hazards. The facility census was 64.
F744 Treatment/Service for Dementia: The facility failed to ensure residents diagnosed with dementia received appropriate treatment and services to maintain their highest practicable well-being. The facility census was 64.
F756 Drug Regimen Review: The facility failed to ensure the pharmacy consultant identified appropriate diagnoses for antipsychotic medication use during monthly medication reviews for one resident. The facility census was 64.
F758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to ensure proper documentation and review of psychotropic drug use, including PRN orders limited to 14 days and appropriate diagnosis documentation.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to thaw food under sanitary conditions, increasing the risk of cross-contamination and foodborne illness. The facility census was 64.
F924 Corridors have Firmly Secured Handrails: The facility failed to ensure handrails on Wing Three were properly attached and secure, posing safety risks. The facility census was 64.
Report Facts
Facility census: 64
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leigh Kyndall | Administrator | Signed the report and plan of correction |
| Director of Nursing | Interviewed regarding care plans and medication use | |
| MDS Coordinator | Interviewed regarding care plans and resident assessments | |
| Pharmacist | Interviewed regarding medication regimen reviews | |
| Cook C | Interviewed regarding food thawing procedures | |
| Dietary Manager | Interviewed regarding food safety and thawing procedures | |
| Maintenance Director | Interviewed regarding handrail repairs |
Inspection Report
Life Safety
Census: 64
Deficiencies: 2
Date: Feb 21, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents.
Findings
The facility failed to maintain the building free of temporary wiring, specifically the improper use of power strips in patient care and other areas. This deficiency potentially affected all residents and staff.
Deficiencies (2)
42 CFR 483.90(a) and NFPA 101: The facility failed to meet the Life Safety Code requirements for electrical equipment, specifically the improper use of power strips in patient care vicinities and other areas. Power strips were observed in use in multiple locations and were not removed as required.
19 CSR 30-85.032(37): Extension cords and duplex receptacles were not used in compliance with electrical safety standards. Extension cords were found under rugs, through doorways, or in locations subject to physical damage.
Report Facts
Facility census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hugh Lyndall | Administrator | Signed the plan of correction and statement of deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Mar 22, 2019
Visit Reason
The inspection was conducted to evaluate compliance with food safety requirements and related sanitary conditions as part of a Performance Improvement Project (PIP) and ongoing regulatory oversight.
Findings
The facility failed to meet food safety requirements related to storage, preparation, and sanitation, including dirt and debris on kitchen equipment and peeling protective coatings exposing rusted metal. The facility implemented a corrective action plan involving cleaning, maintenance, and improved sanitation procedures.
Deficiencies (4)
F812 Food safety requirements. The facility failed to store and distribute food under sanitary conditions, with dirt and debris found on kitchen surfaces and equipment, increasing the risk of cross-contamination and food-borne illness.
A6012 Floor surfaces. Floors in food-preparation and storage areas were not maintained in good repair, contributing to unsanitary conditions.
A6019 Fixtures and vent covers. Light fixtures, vent covers, and similar equipment were not clean and in good repair.
A7056 Nonfood contact surfaces cleaning. Surfaces not intended for food contact were not designed or maintained to be clean and sanitary.
Report Facts
Date of survey completion: Mar 22, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ren Linha | Administrator | Signed the plan of correction and involved in corrective actions |
Inspection Report
Life Safety
Census: 70
Deficiencies: 3
Date: Mar 22, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, focusing on emergency preparedness, egress doors, emergency lighting, and oxygen storage safety.
Findings
The facility failed to maintain fully functioning exit egress doors, required emergency lighting, and proper oxygen tank storage separation. These deficiencies potentially affected all residents and staff.
Deficiencies (3)
K222 Egress Doors: The facility failed to maintain fully functioning exit egress doors, including malfunctioning release mechanisms and locked doors preventing proper egress.
K291 Emergency Lighting: The facility failed to maintain required emergency lighting, including non-functioning emergency lights in the medication room.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain proper oxygen tank separation and storage, with empty tanks mixed with full tanks and inadequate protection from weather.
Report Facts
Facility census: 70
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Date: May 30, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding the care and management of suprapubic catheters and urinary tract infections.
Complaint Details
Complaint #MO142887 was investigated and substantiated based on findings related to catheter care and nursing care deficiencies.
Findings
The facility failed to maintain proper care and management of suprapubic catheters for two residents, resulting in infection control concerns. Observations and interviews revealed improper handling and reuse of catheter drainage bags contrary to manufacturer directions.
Deficiencies (2)
F690: The facility did not ensure proper care and management of suprapubic catheters for residents, including improper handling and reuse of drainage bags, increasing infection risk.
A4074: The facility failed to provide personal attention and nursing care consistent with residents' conditions, as evidenced by the issues noted in F690.
Report Facts
Facility census: 69
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2018
Visit Reason
The inspection was conducted as a full survey and complaint investigation at Shady Oaks Healthcare Center.
Complaint Details
The complaint investigation found no substantiated deficiencies.
Findings
No deficiencies or state licensure deficiencies were cited as a result of this full survey and complaint investigation.
Inspection Report
Life Safety
Census: 69
Deficiencies: 4
Date: Jan 5, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain exit egress doors free from impediments, maintain exit pathways to a public way, maintain emergency egress lighting, and maintain smoke barrier doors with visible fire resistance rating labels. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (4)
K222: The facility failed to maintain an exit egress door free from impediments preventing it from opening during an emergency, affecting all occupants.
K271: The facility failed to maintain exit pathways to a public way, including a two-inch gap in the concrete to the pavement.
K281: The facility failed to maintain emergency egress lighting, with illumination lights not functioning properly.
K374: The facility failed to maintain smoke barrier doors to NFPA code, including painted-over fire resistance rating tags.
Report Facts
Facility census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda S. Hendricks | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Maintenance Supervisor | Interviewed regarding repair and maintenance of exit doors, pathways, lighting, and smoke barrier doors | |
| Maintenance Director | Responsible for repairs and corrective actions in Plan of Correction |
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