01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-04-10 | 7 | 2025-04-10 | 5 |
| Cycle 2 | 2021-11-21 | 11 | 2021-11-21 | 7 |
| Cycle 3 | 2019-09-12 | 1 | 2019-09-12 | 5 |
CMS CCN 3754322026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Shawnee Colonial Estates Nursing Home
535 West Federal Street · Shawnee, OK 74801 · Pottawatomie County
Certified beds161CMS provider file
Recent citation rows36current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
36 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-04-10 · HEALTHF0582Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: Deficient, Provider has date of correction · 2025-05-05 · complaint2025-04-10 · HEALTHF0637Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Correction field: Deficient, Provider has date of correction · 2025-05-052025-04-10 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-05-052025-04-10 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2025-05-05 · complaint2025-04-10 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-05-052025-04-10 · HEALTHF0689Severity K · pattern of immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-05-05 · complaint2025-04-10 · HEALTHF0732Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2025-05-052025-04-10 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2025-05-052025-04-10 · FIREK0300Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Meet other general requirements that are deficient.
Correction field: Deficient, Provider has date of correction · 2025-05-052025-04-10 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-05-052025-04-10 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-05-052025-04-10 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-05-052025-04-10 · FIREK0362Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Correction field: Deficient, Provider has date of correction · 2025-05-052021-11-21 · HEALTHF0576Severity B · pattern; potential for minimal harm
Resident Rights Deficiencies
Ensure residents have reasonable access to and privacy in their use of communication methods.
Correction field: Deficient, Provider has date of correction · 2022-01-192021-11-21 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Correction field: Deficient, Provider has date of correction · 2022-01-192021-11-21 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2022-01-192021-11-21 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2022-01-192021-11-21 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2022-01-192021-11-21 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2022-01-192021-11-21 · HEALTHF0756Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2022-01-192021-11-21 · HEALTHF0758Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Correction field: Deficient, Provider has date of correction · 2022-01-192021-11-21 · HEALTHF0772Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Correction field: Deficient, Provider has date of correction · 2022-01-192021-11-21 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2022-01-192021-11-21 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Correction field: Deficient, Provider has date of correction · 2022-01-1903 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-04-10 | Fine | $44,355 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- TRUMBO, JAYIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST33% · since 08/01/2012
- VINSON, JOHNIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST33% · since 08/01/2012
- LOPEZ, APRILIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 08/16/2021
- PHELPS, KARENIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 11/11/2019
- HEALTH SYSTEMS OF OKLAHOMA, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2003
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.91per resident day
RN hours0.26per resident day
Weekend nurse hours3.55per resident day
Staff turnover47.5%CMS reported field