Health inspection·June 16, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #1's face sheet dated 06/16/2025 revealed a [AGE] year-old male, admitted to the facility on [DATE]. He had the following diagnoses: muscle weakness (decreased strength), muscle wasting and atrophy (loss of strength), unspecified lack of coordination (unable to control movement), osteoarthritis (tissue wears down), genetic related intellectual disabilities (abnormalities in genes or chromosomes), obesity (excessive body fat). Record review of Resident #1's MDS annual assessment dated [DATE] revealed a BIMS score of 15 meaning intact cognitive response. Record review of Resident #1's care plan dated revision date 12/10/2024 revealed Resident #1 is PASRR positive, will participate in quarterly care plan meetings with PASRR representative/social worker, Coordination of PASRR services and Individual Service Plan developed by PASRR representative/social worker. Record review of Resident #1's PCSP dated 12/19/2024 revealed IDT meeting was held on 12/19/2024. Attendees included the resident, the PASRR habilitation coordinator, the Social Worker, MDS RN, and Resident #1. The following NFSS were identified and confirmed: Customized Manual Wheelchair - 3 indicated on-going. During an interview on 06/16/2025 at 9:40 AM, the ADM stated he became aware of a concern with Resident #1's CMWC recently around the end of May 2025. He stated the MDS nurse, and the DOR advised him they were having a hard time getting paperwork completed for Resident #1 for a new customized manual wheelchair. He stated he looked into their concerns and realized they were needing to have the resident assessed for possibly a new wheelchair. He stated the customized manual wheelchair Resident #1 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 676259 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shinnery Oaks Community 711 West Broadway Denver City, TX 79323 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)