Shinnery Oaks Community

Inspectors wroteBased on interviews and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 6 (Resident #9 and #46) residents reviewed for accuracy of assessments. The facility failed to ensure Resident #9 and #46 were coded in the MDS for wander alarm. This failure could place residents at risk for receiving inadequate care and services based on an inaccurate assessment.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, medical records maintained on each resident were accurately documented for 1 of 17 (Resident #47) residents reviewed for accuracy of records. 1. The facility failed to document communication between staff and the MD when Resident #47 was attempting to elope from the facility on 8/30/24. 2. The facility failed to record verbal orders in the EHR when the MD ordered Resident #47 be moved to the secured unit. These failures could place residents at risk for not receiving needed care or treatment after an incident occurred. Findings Included: Record review of Resident #47's undated face sheet reflected Resident #47 was an [AGE] year-old female whose admission date to the facility was on 6/17/24. Resident #47 had the following diagnoses: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an effective Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 7 of 17 residents ( Resident #24, #32, #33, #46, #47,#49, #53) and for 4 of 4 staff (LVN A & B & CNA A& B ) reviewed for infection control in that: All staff were not trained on expectations of providing care to residents with the COVID 19 virus in the memory care unit. 4 out 4 staff were not wearing proper PPE in accordance with the facility droplet/ contact precautions. Residents were not encouraged or redirected to socially distance, use hand hygiene, or wear a mask exposing other residents that did not have the COVID 19 virus. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that: 1) Dietary staff (Dietary Worker A, B and the DM) failed to store, serve or process foods in a manner to prevent contamination, 2) Dietary staff (CNA I, Alternative Dining Worker A, & B) failed to properly wear hair restraints while in the food preparation area, 3) Dietary Staff (Dietary A) failed to exhibit proper handwashing after removal of gloves. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 4 of 17 residents ( Resident #40, #45, #46, and #47) reviewed for resident rights . The facility failed to obtain a signed informed consent from responsible party based on information of the benefits, risks, and options available from for Residents #40, #45, #46, and #47 prior to administering melatonin (sleep aide). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 2 of 24 residents (Residents #15 and 35) reviewed for PASRR screening, in that: Residents #15 and #35 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of major depressive disorder or schizoaffective disorder. These failures could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 14 of 17 residents (Residents #2,#4, #5, #7, #9, #14, #17,#27, #29, #33, #46, #47, #48, and #53) reviewed for care plans as follows: Resident #2 did not have a care plan for visual, behavior, nutritional and pressure ulcer. Resident #4 did not have a care plan for visual, psychosocial wellbeing, falls and psychotropic drug use Resident #5 did not have a care plan for visual function, communication, urinary incontinence, behavior, and dental care. Resident #7 did not have a care plan for visual function, communication, urinary incontinence, and nutritional status. Resident #9 did not have a care plan for urinary incontinence, pressure ulcer and psychotropic drug use. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 17 residents reviewed for adequate monitoring of unnecessary medication (Resident #9). The facility did not monitor Resident #9 for side effects of the anti-anxiety medication Lorazepam (an anxiety medication). This failure could place the residents at risk for adverse consequences of medication.