Shady Oak Nursing And Rehabilitation

Inspection findings

1. Sep 5, 2025 Fire Safety · 7 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Sep 26, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Sep 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0801 Nutrition and Dietary Deficiencies

     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 Sep 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Sep 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Oct 19, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Oct 10, 2025 · CMS fire safety

2. Aug 8, 2024 Health · 6 findings
   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 9, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Aug 9, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Aug 9, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Aug 9, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 9, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Aug 9, 2024 · CMS fire safety

3. Jul 14, 2023 Health · 13 findings
   • Not serious Scope/severity F

     F0570 Resident Rights Deficiencies

     Assure the security of all personal funds of residents deposited with the facility.

     Corrected Aug 9, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Aug 9, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0637 Resident Assessment and Care Planning Deficiencies

     Assess the resident when there is a significant change in condition

     Corrected Aug 9, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Aug 9, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0849 Administration Deficiencies

     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 Aug 9, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0944 Administration Deficiencies

     Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

     Corrected Aug 9, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0946 Administration Deficiencies

     Provide training in compliance and ethics.

     Corrected Aug 9, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0949 Administration Deficiencies

     Provide behavior health training consistent with the requirements and as determined by a facility assessment.

     Corrected Aug 9, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jul 19, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jul 19, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0900 Miscellaneous Deficiencies

     Meet Health Care Facilities Code mechanical requirements.

     Corrected Aug 11, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0916 Gas, Vacuum, and Electrical Systems Deficiencies

     Have a battery powered remote alarm panel in a location accessible by operating personnel.

     Corrected Aug 11, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jul 19, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BLAKE, GARY — adp of the snf, NOT APPLICABLE, since 09/01/2022
• BLAKE, GARY — operational/managerial control, NOT APPLICABLE, since 09/01/2022
• BLAKE, MALISA — operational/managerial control, NOT APPLICABLE, since 09/01/2022
• BOWERS, SEAN — managing control - governing body, NOT APPLICABLE, since 07/01/2024
• CISNEROS, ALFRED — managing control - governing body, NOT APPLICABLE, since 02/18/2008
• COBB, TRAVIS — managing control - governing body, NOT APPLICABLE, since 10/05/2022
• COOPER, STEPHEN — managing control - governing body, NOT APPLICABLE, since 11/11/2022
• HARDIN, SHERRIE — managing control - governing body, NOT APPLICABLE, since 09/04/2024
• HOUSER, HERBERT — adp of the snf, NOT APPLICABLE, since 05/20/2025
• HUGGINS, LINDA — corporate director, NOT APPLICABLE, since 09/01/2022
• KERZEE, RICHARD — managing control - governing body, NOT APPLICABLE, since 09/24/2007
• KORENEK, PATRICIA — managing control - governing body, NOT APPLICABLE, since 05/05/2018
• SOECHTING, PAUL — managing control - governing body, NOT APPLICABLE, since 11/22/2024
• STRACK, JOE — managing control - governing body, NOT APPLICABLE, since 02/11/2022
• THOMAS, JOHN — adp of the snf, NOT APPLICABLE, since 01/01/2025
• THOMPSON, JOHNNY — corporate officer, NOT APPLICABLE, since 01/01/2025
• WILLIG, ZACHARY — corporate director, NOT APPLICABLE, since 01/01/2025
• MOULTON I ENTERPRISES LLC — adp of the snf, NOT APPLICABLE, since 05/20/2025
• MOULTON I ENTERPRISES LLC — operational/managerial control, NOT APPLICABLE, since 09/01/2022