Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Oaks Healthcare Center during CMS and state inspections, most recent first.
Medication administration errors resulted in a 6.25% error rate, exceeding the 5% threshold. Two residents receiving insulin had errors when CMTs failed to properly prime insulin pens before giving ordered doses, and staff interviews showed inconsistent understanding of the manufacturer’s priming instructions. The DON stated medications should be given as ordered and insulin pen administration should follow the manufacturer’s box instructions.
Medication Labeling and Dating Deficiencies: Surveyors found an opened tuberculin PPD vial and multiple opened insulin pens on the med cart that were either not dated or not labeled with a resident name. The facility policy required proper labeling and dating of meds, and the RN and DON stated opened insulin products and tuberculin vials should be labeled when opened and discarded after 28 days.
Failure to use EBP and wear a gown during high-contact care. A resident with a chronic wound and pressure ulcer did not have EBP signage outside the room, and a CNA performed incontinent care without a gown. Another resident with pressure ulcers and chronic wounds had EBP signage posted, but an LPN performed wound care to bilateral surgical incisions without wearing a gown. The IP said EBP was not implemented for the first resident because the wound was classified as MASD, while the DON and Administrator stated residents with pressure ulcers or chronic wounds should be on EBP and staff should wear gown and gloves during high-contact care.
The facility failed to maintain a clean and homelike environment, with observations of soiled blankets, dirt, debris, and dead flies in the library and dining areas. The secured unit shower room had grime buildup, cracked tiles, and inadequate cleaning practices. Housekeeping and maintenance duties were unclear, contributing to the unclean conditions.
The facility failed to ensure appropriate diagnoses for the use of psychotropic medications for several residents, prescribing medications like Seroquel and Risperidone without proper documentation. The administration relied on pharmacy recommendations, believing residents should remain on antipsychotic medications if stable, despite lacking appropriate diagnoses. The facility did not provide a policy or implement gradual dose reductions or non-pharmacological interventions.
The facility failed to employ a qualified director of food and nutrition services, as the Dietary Manager (DM) lacked the necessary experience and credentials. The DM was only enrolled in a one-hour Food Safety course, contrary to the facility's policy requiring more extensive training. Observations revealed issues such as uncleanliness, lack of documentation, and pest control problems in the kitchen. The Administrator was unaware of the need for the DM to have prior long-term care experience, affecting all 64 residents.
The facility failed to maintain sanitary conditions in the kitchen, with dirty floors, debris under equipment, and exposed garbage. Documentation of meal and refrigerator temperatures was inconsistent, and daily cleaning tasks were not always completed. Staff interviews confirmed lapses in documentation and cleaning practices.
The facility failed to maintain infection control practices during wound care for two residents and one outside the sample, and improper glove use was observed. An LPN did not change gloves after touching surfaces before wound care, and a CNA did not follow proper techniques during catheter care, including not changing gloves and placing dirty wipes on bed sheets.
The facility failed to control a fly infestation in the kitchen and dining areas, affecting all residents. Observations showed flies on food and in various areas, with staff unaware of the issue. The Dietary Manager did not report the problem, and the Administrator was uninformed, highlighting a communication breakdown.
Medication Error Rate Exceeded 5% During Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration. Surveyors observed 32 medication administration opportunities and identified 2 errors, resulting in an error rate of 6.25% that affected two residents out of 11 sampled residents. The facility did not provide a policy regarding insulin administration, and the deficiency involved insulin pen use for residents with diabetes mellitus. For one resident, the physician order was for Humalog Kwikpen 10 units subcutaneously with meals after the resident had eaten each meal, but the CMT did not prime the insulin pen before giving the dose. For another resident, the order was for insulin lispro-aabc pen per sliding scale before meals and at bedtime, but the CMT did not attach a needle to the pen and therefore could not properly prime it before administering 7 units. The manufacturer’s instructions reviewed by surveyors required priming the pen before each injection, and staff interviews showed differing understanding of the priming process, including one CMT stating the pen primes itself when dialing the dose and an RN stating the pen was primed by pushing the button without dialing up two units.
Medication Labeling and Dating Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled in accordance with currently accepted professional principles. During observation of the Wing 1/Wing 2 medication storage room, an opened tuberculin purified protein derivative multidose vial was found dated 9/20/25. During observation of the Wing 1 medication cart, surveyors found multiple opened insulin products that were either not dated or not labeled with a resident name, including an insulin aspart pen dated 8/20/25, an opened Lantus pen, an opened Humalog Kwikpen, an opened Basaglar Kwikpen, an insulin lispro Kwikpen labeled with a room number instead of a resident name and dated 09/03/25, and an opened insulin glargine pen that was not dated. The facility policy required medication labels to include the medication name, dose, strength, expiration date when applicable, resident name, route, and instructions, and required opened multidose vials to be dated and discarded within 28 days unless the manufacturer specified otherwise. Manufacturer information reviewed by surveyors stated that the insulin pens used in the facility expire after 28 days once opened or left at room temperature. During interview, the RN stated opened insulin pens and tuberculin vials should be labeled with the resident's name and dated when opened, and the DON stated opened insulin medications and tuberculin vials should be discarded 28 days after opened.
Failure to Use EBP and Wear Gown During High-Contact Care
Penalty
Summary
The facility failed to provide enhanced barrier precautions (EBP) for a resident with a chronic wound and failed to wear a gown during wound care for another resident who required EBP. The facility policy stated that EBP should be used for residents with wounds and/or indwelling or implanted medical devices, and that PPE for EBP is required during high-contact care activities such as wound care, dressing, hygiene, and toileting assistance. For one resident with rheumatoid arthritis, morbid obesity, moisture associated skin damage to the right inner thigh, and a pressure ulcer to the right inner thigh, the record showed an order for wound care to the right medial thigh and a provider note stating the wounds would heal and then open back up for the past two years. During observation of incontinent care, there was no EBP signage outside the room, and a CNA entered the room without a gown and performed incontinent care. The Infection Preventionist stated EBP was not implemented because the wound was classified as MASD and was not aware the wound also had a secondary diagnosis of pressure ulcer. For another resident with bilateral above-the-knee amputations, rectal abscess, type 2 diabetes, morbid obesity, stage three pressure ulcer of the coccygeal region, and chronic ulcer of the sacral region, the record showed the resident required EBP and had multiple wound care orders. During observation of wound care, EBP signage was present on the door and a CNA brought gowns into the room, but the LPN did not put on a gown and performed wound care to both surgical incisions without wearing one. The LPN stated he/she forgot to put on a gown before doing the wound care. The DON and Administrator stated they would expect residents with pressure ulcers or a chronic wound to be on EBP and staff to wear a gown and gloves during high-contact care.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment, as evidenced by multiple observations of unclean conditions. In the library next to the kitchen, two soiled blankets with dirt, debris, and several dead flies were found on the window ledges over three consecutive days. Similarly, the assisted feeding dining room area had a buildup of dirt, debris, and dead flies on the window ledges, along with cobwebs and dirt on the windows facing the designated smoking area. The door leading outside to the picnic table also had a buildup of dirt on its windows. Interviews with housekeeping staff revealed that window cleaning responsibilities were divided between housekeeping and maintenance, with inside cleaning done by housekeeping and outside cleaning by maintenance. However, there was a lack of clarity and coordination in these duties, as evidenced by the unclean conditions. In the secured unit shower room, there was a significant buildup of black grime on the walls and cracked tiles, along with a red rubber hose with a metal clamp used as a makeshift showerhead. The exhaust fan was covered in dust and debris, and a large area of brown dried substance was found under the sink. The housekeeping department was contracted, and the housekeeper mentioned that the cleaning chemicals used were inadequate for mold and mildew removal. The administrator was unaware of the cracked tiles and justified the use of the rubber hose due to the fragility of standard showerheads. These observations indicate a failure to provide a clean and safe environment for the residents.
Inappropriate Use of Psychotropic Medications Without Proper Diagnoses
Penalty
Summary
The facility failed to ensure appropriate diagnoses for the use of psychotropic medications for five residents, both within and outside the sampled group. Residents were prescribed medications such as Seroquel and Risperidone without documented appropriate diagnoses. For instance, Resident #15 was prescribed Seroquel for vascular dementia with agitation and major depressive disorder, but there was no documentation supporting the use of Seroquel for these conditions. Similarly, Resident #18 was prescribed Seroquel for major depressive disorder, yet lacked appropriate documentation for this prescription. The facility's administration and nursing staff expressed reliance on pharmacy recommendations for medication management, indicating a belief that residents should remain on antipsychotic medications if they are stable, despite the absence of appropriate diagnoses. The Director of Nursing acknowledged that many residents with dementia exhibit behaviors that are controlled by these medications, suggesting that discontinuing them could be detrimental. However, the facility did not provide a policy to support these practices, nor did they implement gradual dose reductions or non-pharmacological interventions as required.
Unqualified Dietary Manager and Food Service Deficiencies
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as the Dietary Manager (DM) did not possess the necessary background or required years of experience in food preparation, service, and storage. The facility's policy outlined that the DM's credentials should include a Sanitation Certification, a 90-hour approved Dietary Manager's Course, or a degree in nutrition or food service, as per state regulations. However, the DM, hired in December 2022, was only enrolled in a one-hour Food Safety and Principles - Food Handler Training course, which did not meet the job requirements. The DM had no previous long-term care experience as a dietary manager prior to accepting the position. Observations of the food service department revealed several deficiencies, including a lack of cleanliness in the kitchen, failure to document food temperatures and cleaning schedules, and inadequate pest control. During interviews, the DM stated that they were initially informed they would be enrolled in courses to become a certified dietary manager within a year of hire, but this did not occur. The Administrator, informed by the corporate office, believed that the Food Safety and Principles course was the only requirement for the DM position, unaware of the need for two or more years of experience in a long-term care setting. This oversight had the potential to affect all 64 residents in the facility.
Sanitation and Documentation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and food service areas, which increased the risk of cross-contamination and food-borne illness for all 64 residents. Observations revealed dirty and greasy floors around the food preparation area, visible dirt and debris under various kitchen equipment, and a buildup of dirt and debris on the dishwasher and oven surfaces. Additionally, there was a dark-colored grease-like substance running down a wall, outdated food items on a portable cart, and trashcans with exposed garbage and debris without lids. The ice machine also had a buildup of a hard white substance on its surfaces. The facility's documentation practices were also deficient, with several days lacking records of meal temperature checks and daily freezer/refrigerator temperature logs. The daily cleaning schedule showed gaps in documentation of completed cleaning tasks. Interviews with kitchen staff and the Dietary Manager revealed that food and refrigerator temperatures were not consistently documented, and daily cleaning tasks were not always completed or signed off. The Administrator acknowledged the expectation for daily checks and cleaning to ensure compliance but noted that these tasks were not consistently performed.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care for two residents and one resident outside the sample. Observations revealed that an LPN did not follow the facility's policy by wearing the same protective gown when exiting and re-entering a resident's room to gather supplies, and did not clean the treatment cart after use. This was observed during wound care for two residents, where the LPN did not adhere to the expected protocol of removing the gown before leaving the room and ensuring the treatment cart was sanitized. Another incident involved improper glove use during wound care for a resident. An LPN was observed touching various surfaces with clean gloves and not changing them before performing wound care. The LPN touched a doorknob, bed frame, and call light with clean gloves, and then proceeded to apply Medi-honey to open wounds without changing gloves. This practice was against the expected clean technique and infection control standards, as gloves should be changed whenever they become contaminated. Additionally, during catheter care for a resident, a CNA did not follow proper infection control techniques. The CNA did not change gloves after removing the resident's clothing and used the same gloves to perform catheter care. The CNA also placed dirty wipes on the resident's bed sheet and used a dry paper towel around the catheter insertion area, which was not in line with the facility's policy. These actions were not consistent with the expected standards for infection prevention and control during catheter care.
Fly Infestation in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant fly infestation in the kitchen and main dining room. Observations over several days revealed numerous flies in various areas, including the library next to the kitchen, the assisted feeding dining room, and the kitchen itself. Dead flies were found on window ledges, and live flies were observed crawling on residents' food and clothing during meals. In the kitchen, flies were seen on the steam table, refrigerator, and buzzing around a trashcan without a lid. Interviews with staff indicated a lack of communication and awareness regarding the pest issue. The Dietary Manager acknowledged the fly problem but had not reported it to the administrator. The Maintenance Supervisor stated that department heads are responsible for notifying administration of pest issues, but this had not occurred. The Administrator was unaware of the fly problem until the survey, indicating a breakdown in communication and oversight within the facility's pest control program.
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 15 citations issued within 25 miles in the last 12 months — 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 Thayer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southfork River Therapy And Living | 19 mi | ★★★★★ | 3 | 0 |
| Ash Flat Healthcare And Rehabilitation Center | 20.6 mi | ★★★★★ | 0 | 0 |
| Eaglecrest Nursing And Rehab | 21.2 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, West Plains | 23.3 mi | ★★★★★ | 0 | 0 |
| West Vue Nursing And Rehabilitation Center | 23.3 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Shady Oaks Healthcare 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.