Cycle 1
Health 2025-04-10 · Fire 2025-04-10
8 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Shawnee, OK
Shawnee Colonial Estates Nursing Home
1-star overall rating with 1-star inspections with $44,355 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
535 West Federal Street, Shawnee, OK
(405) 273-7661
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
161
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-02-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.81% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 6.38% · Lower 95% interval 5.83% |
| Discharge to community | 52.27% |
50.57%
1.7 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 45.28% · Lower 95% interval 41.35% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 1 · Denominator 31 · Adjusted rate 2.77% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 2.17% |
8.2%
6 pts worse
|
Numerator 1 · Denominator 46 |
| Staff flu vaccination coverage | 21.05% |
42%
20.9 pts worse
|
Numerator 12 · Denominator 57 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.88% |
25.2%
3.3 pts worse
|
Numerator 7 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
90.3%
8.2 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 100.0% · Q4 100.0% · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
4.5%
About the same
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 4.3% · Q4 6.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.1% |
3.3%
8.8 pts worse
|
11.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 14.3% · Q4 7.7% · 4Q avg 12.1% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
3.6%
1.4 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 5.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
25.3%
11.3 pts better
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 9.5% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
18.6%
15.5 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.4% |
15.5%
12.9 pts worse
|
16.3%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.6% |
14.1%
16.5 pts worse
|
14.9%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 38.1% · 4Q avg 30.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.1%
2.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.8%
2.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.6% |
17.8%
1.2 pts better
|
19.8%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 25.6% · Q4 15.5% · 4Q avg 16.6% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
5.1%
3.9 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 2.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.1% |
75.0%
5.1 pts better
|
81.7%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 86.5% · Q2 72.2% · Q3 74.8% · Q4 93.0% · 4Q avg 80.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.5% |
17.1%
1.4 pts worse
|
12.0%
6.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 19.1% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.5% |
74.0%
20.5 pts worse
|
79.7%
26.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
27.0%
3.2 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 29.8% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-21 · Fire 2021-11-21
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-09-12 · Fire 2019-09-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-04-10
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-04-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-04-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-04-10
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-05-05
F · Potential for more than minimal harm
2021-11-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-19
F · Potential for more than minimal harm
2021-11-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-01-19
E · Potential for more than minimal harm
2021-11-21
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-01-19
E · Potential for more than minimal harm
2021-11-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-01-19
E · Potential for more than minimal harm
2021-11-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-01-19
E · Potential for more than minimal harm
2021-11-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-01-19
E · Potential for more than minimal harm
2021-11-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-01-19
F · Potential for more than minimal harm
2019-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-28
E · Potential for more than minimal harm
2019-09-12
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2019-10-28
E · Potential for more than minimal harm
2019-09-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-10-28
E · Potential for more than minimal harm
2019-09-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-10-18
E · Potential for more than minimal harm
2019-09-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-10-28
Inspection history
Recent health citations
K · Immediate jeopardy
2025-04-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-10
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-10
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-10
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-05
E · Potential for more than minimal harm
2021-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-01-19
E · Potential for more than minimal harm
2021-11-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-01-19
E · Potential for more than minimal harm
2021-11-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-01-19
E · Potential for more than minimal harm
2021-11-21
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-01-19
E · Potential for more than minimal harm
2021-11-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-01-19
D · Potential for more than minimal harm
2021-11-21
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-01-19
D · Potential for more than minimal harm
2021-11-21
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-01-19
D · Potential for more than minimal harm
2021-11-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-19
D · Potential for more than minimal harm
2021-11-21
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2022-01-19
B · Minimal harm
2021-11-21
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-01-19
E · Potential for more than minimal harm
2019-09-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-10-28
Penalties and ownership
What sits behind the stars
$44,355
2025-04-10
Fine
Fine · fine $44,355
Fine
Ownership
Trumbo, Jay
5% Or Greater Direct Ownership Interest · Individual
Vinson, John
5% Or Greater Direct Ownership Interest · Individual
Health Systems Of Oklahoma, LLC
Operational/Managerial Control · Organization
Lopez, April
W-2 Managing Employee · Individual
Phelps, Karen
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Shawnee Care Center
Shawnee, OK
1-star overall rating with 1-star inspections with $22,393 in total fines with 23 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
The Regency Skilled Nursing And Therapy
Shawnee, OK
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Golden Rule Home
Shawnee, OK
2-star overall rating with 3-star inspections with $10,246 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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