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 Shinnery Oaks Community during CMS and state inspections, most recent first.
Inaccurate MDS Coding for Wander/Elopement Alarms: Two residents with severe cognitive impairment and documented elopement risk had wander guard bracelets in place and physician orders for ongoing checks, but their quarterly MDS assessments incorrectly coded the wander/elopement alarm as not used. The MDS nurse acknowledged the coding error and stated both residents should have been marked as using the device daily.
Failure to use required PPE during wound care on two residents on EBP. An RN and an LVN each performed wound care for a resident with a wound while wearing gloves but no gown, despite EBP signage and PPE being available in the room. Both nurses acknowledged that gown use was required for wound care on residents on EBP, and the DON and ADM stated staff were responsible for following EBP PPE requirements.
A facility failed to incorporate PASRR evaluation recommendations into a resident's assessment and care planning by not submitting a complete and accurate NFSS request for a customized manual wheelchair within the required timeframe. Despite the resident's documented needs and an IDT meeting confirming the need for specialized equipment, staff confusion and incomplete paperwork led to the deficiency.
A resident with Lewy body dementia and aggressive behaviors was moved to a secured unit without proper documentation of physician orders and communication with family. The facility staff failed to record verbal orders in the EHR, despite policies requiring immediate documentation. This oversight could risk residents not receiving necessary care.
Inaccurate MDS Coding for Wander/Elopement Alarms
Penalty
Summary
The facility failed to ensure the quarterly MDS assessments accurately reflected the use of wander/elopement alarms for 2 of 6 residents reviewed, Resident #9 and Resident #46. For Resident #9, the record showed diagnoses including Alzheimer's dementia, hypertension, anxiety, and muscle weakness, with a BIMS score of 00 indicating severely impaired cognition. Although the care plan identified elopement risk and wandering behavior and included interventions such as a wander guard, and physician orders directed staff to check the wander guard placement and functioning, the quarterly MDS marked the wander/elopement alarm as not used. During observation, Resident #9 was seen sitting in a wheelchair with a wander guard bracelet on the right ankle. For Resident #46, the record showed diagnoses including Alzheimer's dementia, hypertension, cerebral infarction, and muscle weakness, with a BIMS score of 04 indicating severely impaired cognition. The care plan addressed elopement risk and included a wander guard on the left lower extremity, and physician orders directed staff to check the wander guard placement and functioning for elopement risk. Despite this, the quarterly MDS also marked the wander/elopement alarm as not used. During observation, Resident #46 was seen sitting in a recliner with a wander guard bracelet on the left ankle. During interviews, the MDS nurse stated both residents should have been marked as using the wander guard daily and acknowledged the MDS was not coded correctly. She stated she was responsible for making sure the MDS was accurate and that she missed marking the correct response. The DON and ADM stated the MDS should reflect the resident's condition and care and that the IDT was responsible for accurate coding. The facility policy stated quarterly MDS assessments are conducted to track resident status between comprehensive assessments, and the CMS RAI manual states wander/elopement alarms should be coded based on use during the 7-day look-back period.
Failure to Use Required PPE During Wound Care on EBP Residents
Penalty
Summary
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 two residents who were on Enhanced Barrier Precautions (EBP) for wounds. Resident #13 was a female with diagnoses including Alzheimer’s disease, peripheral vascular disease, and a pressure ulcer of the left ankle. Her care plan and physician’s orders reflected treatment for the left ankle pressure injury and EBP requirements for wound-related care, including wearing a clean gown and gloves during high-contact resident care activities. During an observation, RN A performed wound care to Resident #13’s left ankle while wearing gloves but without a gown, despite EBP signage posted at the room and PPE supplies available inside the room. During an interview, RN A stated she did not put on a gown before the wound care and acknowledged that a gown should be worn when conducting direct care, including wound care, for a resident on EBP. She also stated she had been trained on EBP through in-services conducted by nursing administration. Resident #28 was a male with diagnoses including atrial fibrillation, pressure-induced deep tissue damage of the right foot, and unspecified dementia. His care plan and physician’s orders reflected treatment for the right foot wound and EBP requirements for wound-related care. During an observation, LVN B performed wound care to Resident #28’s right foot while wearing gloves but without a gown, despite EBP signage posted at the bed and PPE supplies available in the room. During an interview, LVN B stated she did not put on a gown before the wound care and acknowledged that a gown should be worn when conducting direct care, including wound care, for a resident on EBP. The ADM and DON stated staff were responsible for using proper PPE during EBP care and that nursing administration was responsible for monitoring and training staff.
Failure to Incorporate PASRR Recommendations and Submit Timely NFSS Request
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR evaluation report into the assessment, care planning, and transition of care for a resident identified as PASRR positive. Specifically, after an IDT meeting where the need for a new customized manual wheelchair (CMWC) was discussed and confirmed, the facility did not submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC online portal within the required 20-day timeframe. The process for obtaining the CMWC was not completed as outlined, and the necessary forms and documentation were not submitted as required by policy. Record review showed that the resident had multiple diagnoses, including muscle weakness, muscle wasting, lack of coordination, osteoarthritis, genetic-related intellectual disabilities, and obesity. The resident's care plan indicated participation in quarterly care plan meetings with PASRR representatives and coordination of PASRR services. Despite these documented needs and the identification of the CMWC as an ongoing requirement, the facility did not follow through with the necessary steps to secure the recommended equipment. Interviews with facility staff revealed confusion and lack of familiarity with the PASRR and NFSS processes. The MDS nurse, DOR, and other staff members indicated difficulties in completing the required paperwork and uncertainty about who was qualified to sign the necessary forms. The DME company evaluated the resident and determined that a new CMWC was not immediately needed, but repairs were required. Despite internal communications and attempts to clarify the process, the facility ultimately did not submit the NFSS form within the mandated timeframe, resulting in a failure to coordinate and provide the recommended PASRR services.
Failure to Document Physician Orders and Communication
Penalty
Summary
The facility failed to accurately document medical records for a resident, identified as Resident #47, who was at risk of elopement and exhibited aggressive behaviors. The resident, a female with multiple diagnoses including Lewy body dementia and major depressive disorder, was admitted to the facility and later identified as an elopement risk. On a specific date, the resident attempted to elope, and the facility staff failed to document communication with the physician regarding this incident. Additionally, verbal orders from the physician to move the resident to a secured unit were not recorded in the Electronic Health Record (EHR). Interviews with facility staff revealed that the resident exhibited aggressive behaviors, such as hitting staff and attempting to leave the facility, which prompted the decision to move her to a secured unit. However, the necessary documentation, including the physician's verbal orders and the communication with the family, was not completed in a timely manner. The staff, including the Licensed Vocational Nurse (LVN) and the Social Worker (SW), acknowledged the oversight in documentation, attributing it to the hectic situation at the time. The facility's policies require that all verbal orders be documented immediately in the resident's medical record, including the date, time, and signature of the person receiving the order. Despite these policies, the documentation was not completed, which could potentially lead to residents not receiving necessary care or treatment. The facility's administration and nursing staff were aware of the documentation requirements but failed to adhere to them in this instance.
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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.
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Nursing homes near Denver City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memorial Health Care Center | 19.2 mi | ★★★★★ | 0 | 0 |
| White Sands Healthcare | 25 mi | ★★★★★ | 14 | 2 |
| Desert Springs Health Care Llc | 25.2 mi | ★★★★★ | 12 | 0 |
| Lovington Healthcare Llc | 31.9 mi | ★★★★★ | 3 | 0 |
| Brownfield Rehabilitation And Care Center | 35 mi | ★★★★★ | 0 | 0 |
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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.