Shawnee Colonial Estates Nursing Home

In the surveyor’s words

From the most serious findings on record at Shawnee Colonial Estates Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 10, 2025

  On 04/08/25 at 3:50 p.m., the Oklahoma State Department of Health was notified and verified the existence of an Immediate Jeopardy situation related to the facility's failure to provide supervision to prevent elopement from the facility. Resident #22 was identified as being at risk for elopement. Resident #22 made it out to the parking lot through the front door within sight of the nurse's station unattended. A visitor notified staff Resident #22 was in the parking lot. On 04/08/25 at 3:55 p.m., the administrator, director of nursing, assistant director of nursing, business office manager, and corporate nurse were notified of the immediate jeopardy and provided the immediate jeopardy template. […]

• No harm, potential for more than minimal, patternF689Nov 21, 2021

  Based on observation, record review, and interview, the facility failed to: a. firmly attach toilet seat risers to the toilet seats for four (#12, 34, 45, and #49) of seven sampled residents reviewed for accident hazards. b. thoroughly investigate the root cause of falls and implement interventions to prevent further falls for one (#58) of three sampled residents reviewed for falls. The Resident Census and Conditions of Residents identified 77 residents who resided in the facility. Findings: 1. During the resident (Res) council meeting, on 11/18/21 at 9:22 a.m. with ten cognitively intact residents the following statements were made related to toilet seat risers: a. Res #34 stated the handles on her commode was not sturdy. […]

• No harm, potential for more than minimal, patternF755Nov 21, 2021

  Based on interview and record review, the facility failed to provide pharmaceutical services for one (#128) of six sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents report documented 77 residents resided in the facility. Findings: Resident (Res) #128 was admitted to the facility on [DATE] and had diagnoses which included [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], anxiety, and hallucinations. A nurse note, dated 01/15/20 at 12:01 a.m., documented the resident had been up numerous times throughout the night, with and without clothes, asking for money, relatives, and shopping lists, etc. […]

• No harm, potential for more than minimal, patternF756Nov 21, 2021

  Based on interview and record review, the physician failed to respond to pharmacist MRRs timely and according to the facility's policy for three (#10, 62, and #77) of five sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents report documented 77 residents resided in the facility. Findings: The facility's undated Drug Regimen Review'' policy read in parts, .The report is provided by the Consultant Pharmacist or facility to the Primary Physician and the Director of Nursing within seven working days of review, or according to facility policy. The physician provides a written response of the report to the facility within one month after the report is sent . 1. […]

• No harm, potential for more than minimal, patternF758Nov 21, 2021

  Based on record review and interview, the facility failed to follow a physician's order to reduce a [CONDITION(S)] medication for one (#39) of five sampled residents reviewed for unnecessary medications. The DON identified 37 residents who received antidepressant medications. Findings: Resident (Res) #39's diagnoses included major depressive disorder. A physician order, dated 05/21/21, documented the resident was to have received [MEDICATION(S)] (an antidepressant medication) 30 mg q day. A pharmacist MRR, dated 09/16/21, documented the pharmacist made a recommendation to the physician to attempt to reduce the dosage of the resident's [MEDICATION(S)] from 30 mg to 20 mg q day. The pharmacist MRR, dated 09/16/21, documented the physician agreed to the reduction on 11/15/21. […]