Health inspection·December 11, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete daily. During an interview on 12/11/2025 at 08:50 AM with the MDS Nurse, the MDS nurse stated the purpose of the MDS was to accurately put all resident information. The MDS nurse stated she was not aware the MDS's was not coded correctly. She stated she missed marking the right response and needs to pay closer attention. She stated she had received training on MDS. She stated she was responsible for making sure the MDS was accurate. She stated her expectations was for the MDS to be as accurate as possible. She stated she was not sure how she missed coding the wander alarm. She stated there was a new update on 09/01/2025 and she was still learning all the changes. She stated Residents #9 and #46 had wander guard bracelets at the time of the MDS assessment. She stated the potential negative outcome could possibly affect the resident depending on the situation. During an interview on 12/11/2025 at 08:50 AM with the DON, she stated the purpose of the MDS was collection of data to develop a care plan. She stated she was not aware the MDS's was coded inaccurately. She stated the potential negative outcome could affect the residents by causing an inaccurate care plan.During an interview on 12/11/25 at 09:01 AM with the ADM, he stated the purpose of the MDS was to reflect the resident's condition and care. He stated he was not aware the MDS was not coded correctly. He stated all staff have been trained. He stated the IDT was responsible for accurately coding the MDS. He stated his expectation was for the MDS to be coded correctly. He stated the potential negative outcome could be the potential to not have a proper care plan. Record review of the facility's Quarterly Assessments Policy dated 2001 revealed: Policy Statement Quarterly MDS assessments are conducted to track the resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. Record review of CMS's RAI version 3.0 dated October 2025 revealed section: P0200: AlarmsP0200 Alarms: An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. Coding: 0. Not used, 1. Used less than daily, 2. Used daily.E. Wander/elopement alarm.Steps for Assessment:Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if alarms were used during the 7-day look-back period.Coding Instructions:Identify all alarms that were used at anytime (day or night) during the 7-day-look-back period. After determining whether or not an item listed in P0200 was used during the seven day look back, code the frequency of use:Code 0, not used: if the device was not used during the 7-day-look-back period. Code 1, used less than daily: if the device was used less than daily.Code 2, used daily: if the device was used on a daily basis during the look-back period. Coding Tips: .Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, care) or other belongings.Code any type of alarm, audible or inaudible, used during the look-back period in this section.Bracelets or devices worn by or attached to the resident and/or their belongings that signal a door to lock when the resident approaches should be coded in P0200E. Wander/elopement alarm, whether or not the device activates a sound or alerts the staff. Event ID: Facility ID: 676259 If continuation sheet Page 2 of 4 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 12/11/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #13 and #28) reviewed for infection control. 1. RN A failed to wear proper PPE (a gown) when providing wound care for Resident #13 who was on EBP. 2. LVN B failed to wear proper PPE (a gown) when providing wound care for Resident #28 who was on EBP. These failures could place residents at risk for the spread of infection and cross contamination. 1. Record review of Resident #13's face sheet, dated 12/10/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included: Alzheimer's Disease (a progressive brain disorder leading to severe cognitive decline), peripheral vascular disease (a circulatory problem resulting in reduced blood flow, and pressure ulcer of the left ankle. Record review of Resident #13's annual MDS, dated [DATE], reflected an unscored BIMS, due to the resident was rarely or never understood. Section - M - Skin Conditions reflected the resident was at risk of developing pressure ulcers. Section - G - Functional Abilities reflected the resident was dependent on staff for transfers, bathing, and toileting and required substantial/maximal assistance for eating. Record review of Resident #13's Comprehensive Care Plan, dated 10/29/25, reflected the resident had a pressure ulcer to the left ankle. Interventions included: Administer treatments as ordered and monitor effectiveness. EBP in place. Record review of Resident #13's current Physician's Orders, dated 12/10/25, reflected an order with a start date of 11/21/25 to treat the pressure injury to left ankle and apply a dressing. Further review reflected an order for Enhanced Barrier Precautions related to wounds which stated staff members will wear a clean gown and gloves while performing high contact resident care activities. During an observation on 12/10/25 at 9:40 AM, RN A performed wound care to Resident #13's left ankle wound, per physician's orders. RN A put on gloves but failed to put on a gown prior to performing wound care for Resident #13. Enhanced Barrier Precaution signage was noted to the door of Resident #13's room and a supply of PPE was noted inside Resident #13's room. During an interview on 12/10/25 at 2:48 PM, RN A stated she did not put on a gown prior to performing wound care for Resident #13 who was on EBP. She stated she did not think to put on a gown due to being nervous during the observation of wound care. She stated she had been trained on EBP through in-services conducted by nursing administration. RN A stated a gown should be worn when conducting direct care, including wound care, on any resident who was on EBP. She stated a potential negative outcome for failure to utilize proper PPE during direct care of a resident on EBP was infection. 2. Record review of Resident #28's face sheet, dated 12/10/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #28 had diagnoses which included: atrial fibrillation (a type of irregular heartbeat which makes the heart less efficient at pumping blood), pressure-induced deep tissue damage of other site (a pressure sore), and unspecified dementia. Record review of Resident #28's quarterly MDS, dated [DATE], reflected a BIMS score of 02, which indicated the resident had severe cognitive impairment. Section - M - Skin Conditions reflected the resident was at risk of developing pressure ulcers. Record review of Resident #28's Comprehensive Care Plan, revised 11/25/25, reflected the resident had a DTI to the 3rd digit on the right foot. Interventions included: Administer treatments as ordered and monitor effectiveness. Enhanced Barrier Precautions; staff members will wear a clean gown and gloves while performing high contact resident care activities. Record review of Resident #28's current Physician's Orders, dated 12/10/25, reflected an order with a start date of 11/26/25 to treat deep tissue injury to the 3rd digit of the right foot Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676259 If continuation sheet Page 3 of 4 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 12/11/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and apply a dressing daily. Further review reflected an order for Enhanced Barrier Precautions related to wounds and stated staff members will wear a clean gown and gloves while performing high contact resident care activities. An order with a start date of 12/09/25 reflected, Enhanced Barrier Precautions related to wounds. During an observation on 12/10/25 at 9:49 AM, LVN B performed wound care to Resident #28's right foot wound, per physician's orders. LVN B put on gloves but failed to put on a gown prior to performing wound care for Resident #28. Enhanced Barrier Precaution signage was noted to the foot of Resident #28's bed and a supply of PPE was noted inside Resident #28's room. During an interview on 12/10/25 at 2:52 PM, LVN B stated she did not put on a gown prior to performing wound care for Resident #28 who was on EBP. She stated she was unsure why she did not put a gown on before performing wound care. She stated, I guess I was just nervous because I normally put a gown on before doing wound care. LVN B stated she had been trained on EBP approximately quarterly through in-services conducted by nursing administration. LVN B stated a gown should be worn when conducting direct care, including wound care, on any resident who was on EBP. She stated a potential negative outcome for failure to utilize proper PPE during direct care of a resident on EBP was infection and cross-contamination. During an interview on 12/11/25 at 3:43 PM, the ADM stated he was not aware staff were performing wound care on EBP residents without utilizing proper PPE. He stated a gown should be worn during wound care of a resident on EBP. The ADM stated the nurse performing wound care was responsible for utilizing proper PPE. He stated nursing administration was responsible for monitoring staff to assure EBP guidelines and standards of care were followed. The ADM was asked to state a potential negative outcome for failure to utilize proper PPE during direct care of a resident on EBP and he stated, I cannot assume what the negative outcome would be. During an interview on 12/11/25 at 3:50 PM, the DON stated the direct care nurse was responsible for utilizing proper PPE during care of an EBP resident. She stated nursing administration was responsible for monitoring, training and assuring staff adhere to EBP guidelines. The DON stated the ADON conducted rounds in the facility to monitor and ensure staff were following EBP guidelines. She stated staff were trained on EBP through in-services conducted by nursing administration. The DON stated a potential negative outcome for failure to utilize proper PPE during direct care of a resident on EBP was the transfer of diseases. Record review of the facility's undated sign posted outside Resident #13's door and on the foot of Resident #28's bed, titled, Enhanced Barrier Precautions, reflected: PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities .Wound Care; any skin opening requiring a dressing Record review of the facility-provided policy titled, Modified Isolation or Enhanced Barrier Precautions; Based on guidance recommendation from the Centers for Disease Prevention and Control 07/2022, reflected: Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDROs to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier: .Wound care: any skin opening requiring a dressing. Event ID: Facility ID: 676259 If continuation sheet Page 4 of 4